Remote Lpn Clinical Engagement And Care Plan Coordination

Commonwealth Care Alliance Clinical Engagement and Care Plan Coordination LPN is primarily responsible for engaging hard-to-reach members and members unwilling to participate in the onboarding and Care Planning process.

The Clinical Engagement and Care Plan Coordination LPN leads efforts to locate and engage hard-to participate members telephonically. He/she does this in collaboration with the Onboarding and Engagement team through research to identify accurate contact information for these members. The Clinical Engagement and Care Plan Coordination LPN works to gain trust and agreement from members to participate in the onboarding or Care Planning process; determine to forge trusting relationships and engages individuals not readily interested in such activities. This individual also collaborates with the other departments within CCA and external providers in research efforts to locate members.

• In collaboration and support from the Onboarding and Engagement Team, uses internal and external resources (such as claims, referrals, and pharmacy data) to identify accurate, successful modes of communication with unreachable members.
• Adheres to appropriate and complete member centered Care Plan documentation practices for members who are unreachable for the initial MDS assessment and/or unwilling to participate in the onboarding and Care Planning process.
• On a semiannual or annual basis, reviews and updates the member-centered Care Plan.
• For unreachable member, if reached and willing to participate in the MDS process, review Care Plan with the member, assists and assign member to the Onboarding and Engagement team to schedule the MDS assessment and ensure that he or she is available to the member.
• Within a defined (onboarding of new members) period of time, conduct a telephonic Care Plan with new members who are unwilling to participate in the MDS assessment but willing to discuss and engaged in the development of the Care Plan.
• Utilizes Clinical Decision Support Tools and consultation with CCA specialist, authorizes proposed equipment and/or services for the implementation of the individualized plan of care and collaborate with CCA Authorization Unit staff to ensure appropriate medical necessity criteria are met. Participates in utilization and case review as necessary.
• Utilizes and depending on CCA internal resources, ensures that the member-centered plan of care is implemented in timely manner.
• Conveys the purpose of the MDS assessment, program to the member and member's care giver.
• Assist members in utilizing resources, including scheduling appointments, transportation and in home services.
• Utilizes established workflows and collaborates with internal stakeholders such as : Member Services, Onboarding and Engagement Team, Enrollment, Clinical Response Unit, Transition of Care, UM and Care Partners
• Collaborate with the Transition of Care Team for inpatient and post discharge member follow up.
• Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and Care management services.
• Provides consultation and support to other members of CCA Care Team.
• Other duties as assigned by manager
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 24hours of activity, and returning non-urgent calls within 48 hours.
• Actively participates in the evaluation of own performance and progress.
• Participates in activities and education to maintain and advance competency Participates in CCA quality improvement efforts.
• Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects.
• Participates in committees and workgroups that promote clinical excellence and help to advance CCAsmission and business objectives.