ACO Clinical Nurse Liaison/Continuum Care Manager
Accountable Care Associates - Auburn, MA

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POSITION TITLE: (ACO Clinical Nurse Liaison / Continuum Care Manager) CNL/CCM
Location: Auburn, MA

The ACO (Accountable Care Organization) Care Manager will strategically manage services for Medicare fee-for-service beneficiaries. The CNL/CCM will be responsible in assisting patients and practitioners to navigate the health care system and support care management activities. The CNL/CCM will facilitate information exchange as patient’s transition between levels of care; conduct population analysis and implement management strategies to address possible gaps in care. The education of the patient and his/her family will be incorporated into the care plan after careful assessment of the patient’s knowledge base, home life, and post-acute resources. ACO care managers will help ensure the patient receives the right services at the right level of care and will assist the patient and their physician in navigating care at an optimum level.

This a full-time 8 hour position per day, no weekends.


• As a team member the CNL/CCM must possess excellent communication skills both written and verbal, and an ability to listen and be assertive, as required.
• Excellent interpersonal skills, with a flexible and creative approach to problem solving are also required.
• The CNL/CCM utilizes sound clinical judgment, decision-making skills and critical thinking skills to coordinate services based on defined needs.
• An ability to work independently and effectively as a member of an interdisciplinary team is essential.
• Central to the role of CNL/CCM is a commitment to “coaching” (rather than “teaching”) patients to improve their health behavior to attain their health-related goals.
• The CNL/CCM will have a clear understanding of the role, and will demonstrate a commitment to implementation of the following accountabilities.

Key Responsibilities:

• Facilitates coordination of care transitions for a subset of members by:
• Collaborating with hospital discharge planners to identify member needs and facilitate transition of care.
• Communicating goals for care to receiving providers (rehabilitation facility, nursing home, home care).
• Ensuring that relevant providers receive timely clinical data for care treatment decisions in all settings of care (rehabilitation facility, nursing home, home care).
• Management and coordination of all transitions in care.
• Communicate care plan to all providers in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialist).
• Ensure that relevant providers receive timely clinical data for care treatment decisions in all settings of care (ED, hospital, rehabilitation facility, nursing home, home care and specialty care).
• Refer Comprehensive care management and care coordination for complex members who require intensive management.

Minimum requirements:

• Current unrestricted Massachusetts licensure as a registered nurse required.
• Minimum five years of nursing experience, preferably with the geriatric population; BSN, CCM preferred.
• Proficient in use of clinical criteria; knowledge in application of InterQual criteria preferred.
• Demonstrates knowledge of Medicare guidelines required
• Proficient in identifying measurable functional rehab goals.
• Proficient in computer use, the Internet, and health information technology.
• Certification in geriatric nursing or geriatric Care Management a plus.
• Ability to travel frequently (25%) to hospitals, skilled nursing facilities, patients’ homes, and other sites where patients receive care (as indicated by patients’ needs) throughout Central MA.

About Accountable Care Associates:

Accountable Care Associates is an innovative MCO healthcare management services organization, developer and vendor of nationally recognized best-in-class proprietary IT, data, infrastructure, and management solutions for healthcare providers, institutions, payors, and others in the healthcare industry. ACA provides services and infrastructure solutions, including managing and partnering on global risk contracts and ACO model structures.
ACA offers data warehouse, data analytics, quality metrics, reporting, risk adjustment, and compliance support services. ACA’s team manages Medicare programs, case management services, disease management services, Blue Cross Blue Shield AQC, and other commercial programs. Under the guidance of founder and chairman, Dr. Phil Gaziano, the ACA leadership team has developed managed care infrastructure, including case management, complex disease management, coding, data analytics, and dedicated hospital rounding programs.
ACA continues to develop and provide innovative, leading-edge, services in global capitation programs and the organization was one of the first in its home state of Massachusetts to become delegated to do its own complex disease management. Quality, efficiency, and member satisfaction measures have continued to improve, and enrollment in global capitation ACO-type programs have continued to grow based on ACA’s proven track record of performance and success for partners and clients.

Summary Benefit Program:
PAID TIME OFF (PTO) AND HOLIDAYS: 18 days per year and 9 holidays per year

HEALTH INSURANCE: We currently offer Blue Cross/Blue Shield HMO Blue Value NE and a PPO plan. This pre-tax deduction can be arranged for you individually or for the whole family.

DENTAL INSURANCE: We currently offer Dental Blue for individual or family coverage.

VISION INSURANCE: Vision insurance is offered through VSP with a 4 tier program of coverage.

LIFE INSURANCE & ACCIDENTAL DEATH & DISMEMBERMENT: This is totally free of charge for you! The insurance plan has a value equal to your annual salary, so as your salary increases so does the value of your life insurance. You may also choose to purchase additional insurance coverage for you and your dependents. (maximums amounts do apply)

ADDITIONAL ANCILARY BENEFITS: Accountable Care will also provide employees with a means to purchase at group rates for additional life, dependent life, short term disability and cancer insurance, just to name a few options.

SHORT TERM DISABILITY: STD is offer at no charge to our employees scheduled 32 hours or more. Should you become sick or disable you would receive 60% of your pre-disability income (some restrictions do apply)

LONG TERM DISABILITY: LTD is offered at no charge to our employees scheduled 32 hours or more. Should you become sick or disabled you would receive 60% of your gross monthly income (some restrictions do apply).

401(k) RETIREMENT SAVINGS PLAN: Allows you to save money and plan for retirement through pre-tax payroll deductions after one year of service. Company contribution after 12 consecutive months of employment. Enrollment allowed the first quarter after your first year of employment.

FLEXIBLE SPENDING ACCOUNTS (Dependent Care and Health Care): By opening a heath care or dependent care spending account, you may reimburse yourself for medical and/or dependent care expenses on a tax-favored basis, with dollars that are not subject to federal, state, and social security taxes.

EMPLOYEE REFERRAL PROGRAM: Up to $1,000 for exempt positions, $500 for non-exempt (hourly) positions. (some restrictions do apply).

EMPLOYEE ASSISTANCE PROGRAM: Confidential free service designed to assist you or your family members with financial concerns, legal questions, behavioral issues, substance abuse and work related problems. Counselors are available 24/7 365 days a year.

Please send resumes to:

Clint Berge
HR Director
One Monarch Place, 10th Floor
Springfield, MA 01144

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