• Work in a professional and confidential capacity related to all program services and communications.
• Provide clinical support and health care strategies for the Community Partner Team (CPT) including outreach to hospitals, emergency departments, and community resources to assure appropriate referrals and information gathering to optimize health and wellness services for the Enrollee to prevent future ED and inpatient admissions/re-admissions, as appropriate.
• Assist with Transitions of Care for Enrollees with complex health needs, including but not limited to, working with CPT as the lead point of contact to assure integrated care between ACO/MCO, PCP, CP staff, providers, and other Care Team members.
• Provide both telephonic and in-person consultation for acute changes of status in Enrollees.
• Review and approve the Enrollee’s medical history, medical needs, medications, and functional status, including needs for assistance with any Activities of Daily Living and Instrumental Activities of Daily Living as outlined in the Comprehensive Assessment.
• Assist with the development of care plan goals to improve health outcomes.
• Conduct clinical review and sign-off approval on Comprehensive Assessments and LTSS-CP Care Plans created by LTSS-CP Care Coordinator/Outreach Specialists to ensure they are clinically appropriate for program Enrollees.
• Assist with enhancing the program’s ability to capture medical information, including gaps in care to determine where health disparities exist, and solutions to close those gaps.
• Conduct medication reviews and document such reviews in the Enrollee’s EHR.
• Provide training and support to Care Coordinators/Outreach Specialists to enhance their ability to support the wellness goals of their members, including strengthening health and wellness coaching, use of SBAR, understanding risk factors, etc.
• Provide case consultation and/or attendance at Integrated Case Conferences for Enrollees with complex medical and/or social determinants of health (SDOH) needs.
• Collaborate with ACO teams and serve as a team resource.
• Maintain all documentation required for the delivery of LTSS Community Partners services including other data entry into EHR, as required.
• Attend regular supervisory meetings both on a team and individual basis, as required.
• Participation in ongoing CQI activities.
• Maintain cultural competency awareness and sensitivity to cultural, religious, ethnic, disability, and gender/sexual orientation issues.
• Triage and balance competing priorities.
• Work independently as well as part of a multidisciplinary Care Team.
• Provide oversight and supervision of LPN staff.
• Respond to reasonable expectations of the Agency and/or supervisor.

• Registered Nurse (RN) licensed in the Commonwealth of Massachusetts in good standing
• Experience working with youth and adults, individuals with complex medical needs, and disabled populations ages 3 - 64.

• Long-term disability insurance
• Life insurance
• 403b pension plan
• Flexible spending account
• Three weeks of paid vacation
• Twelve paid holidays
• Generous earned sick time.

Family Service Association is a comprehensive private, non-profit social service agency dedicated to the development and implementation of services designed to provide strength and support to individuals and families throughout southeastern Massachusetts. Headquartered in Fall River, Family Service Association strives to increase the capacity of individuals and families to cope with the stresses of family life and interpersonal relationships in a positive, productive and health-improving manner. This agency is a leading provider of professional social services in the South Coast region of Massachusetts, with a 130-year tradition of high quality.