EverCare Nurse Practitioner

Geriatric Nurse Practitioner

Assumes responsibility and accountability as the primary clinician for a panel of geriatric patients within the EverCare practice. The EverCare Nurse Practitioner provides the majority of bedside and longitudinal primary care, including comprehensive assessment, diagnosis, treatment, chronic disease management, and care coordination for medically complex older adults across office, home, and facility settings. Services are provided under a collaborative practice agreement with the physicians of the practice. The NP provides clinical direction to the EverCare Registered Nurses delivering chronic care management services and is accountable, together with the interdisciplinary team, for the quality, patient experience, utilization, and total cost of care outcomes that drive the practices performance in the Accountable Care Organization (ACO) and other value-based arrangements. Participates in the on-call schedule per on-call policy.

Essential Functions:

• Clinical Care:
• Serves as the primary clinician for an assigned panel of geriatric patients, providing longitudinal primary care in office, home, assisted living, and skilled nursing settings as assigned.
• Completes and documents accurate, comprehensive histories and physical examinations; provides diagnosis and treatment of acute and chronic conditions, including ordering and interpreting diagnostic tests and prescribing medications and treatments according to the collaborative practice agreement and NP scope of practice laws, as approved by the Medical Director.
• Performs comprehensive geriatric assessments addressing chronic disease burden, functional status, cognition, mobility and fall risk, sensory impairment, nutrition, continence, mood, polypharmacy, caregiver capacity, and social determinants of health.
• Conducts Annual Wellness Visits (AWVs), Initial Preventive Physical Exams (IPPEs), and comprehensive visits that support accurate and complete documentation of all active diagnoses to the highest level of specificity, supporting risk adjustment data integrity and appropriate care planning.
• Performs proactive medication management for older adults, including deprescribing of potentially inappropriate medications, simplification of regimens, and medication reconciliation at every encounter and following all transitions of care.
• Manages acute changes in condition with a treat-in-place approach whenever clinically appropriate, including urgent visits, telehealth assessment, and after-hours telephone management, to prevent avoidable emergency department visits and hospitalizations.
• Leads timely post-discharge care following hospital, emergency department, and skilled nursing facility stays, including Transitional Care Management (TCM) visits within required timeframes, in coordination with the EverCare RN.
• Provides and documents advance care planning, goals-of-care, and end-of-life discussions with patients, families, and legal representatives; completes and maintains advance directives and POST/POLST documentation; coordinates timely referral to palliative care and hospice services when appropriate and requested.
• Establishes and updates individualized, patient-centered care plans in collaboration with the EverCare RN, and provides clinical direction for the RNs chronic care management activities, including reviewing escalations, co-signing care plans as required, and prioritizing outreach for high-risk patients.
• Care Coordination and Communication:
• Coordinates with internal and external members of the patients health care and family/caregiver teams, including specialists, hospitals, facilities, home health, behavioral health, pharmacies, and community agencies, to ensure continuity of care across all settings.
• Maintains consistent, ongoing communication with the collaborating physician regarding patient status and all aspects of care, and consults with physicians within the practice according to the collaborative practice agreement.
• Communicates with nursing home, assisted living, and other facility staff regarding goals of care and treatment plans.
• Leads and participates in interdisciplinary team (IDT) meetings, daily huddles, and panel review sessions to review high-risk patients, utilization events, and care plan changes.
• Completes timely and accurate documentation of all encounters in the electronic medical record (EMR) to support medical necessity, coordination of care, quality and coding standards, risk adjustment accuracy, and practice metrics.
• Participates in the on-call schedule per on-call policy, providing telephone management and visits as needed.
• Value-Based Care, Quality, and Practice Citizenship:
• Actively contributes to the practices performance in the ACO and other value-based arrangements, including total cost of care, quality measures (e.g., MSSP, HEDIS, Medicare Advantage Stars), patient experience, and utilization targets.
• Reviews and acts on population health, risk stratification, quality gap, and utilization reports for the assigned panel; partners with the EverCare RN to close care gaps and prioritize outreach.
• Ensures documentation and coding accurately reflect patient complexity and services delivered, in compliance with all Medicare and payer requirements.
• Participates in Quality Assurance activities and committee service related to NP scope of practice, clinical protocols, and policies/procedures.
• Provides educational support to the orientation process, ongoing staff development, and education about the organizations services to referral sources, facilities, and the community.
• Proactively supports panel growth within designated region(s) and seeks to offer care that meets the unmet and diverse needs of the community.
• Maintains oversight of all allocated resources within assigned areas of responsibility including but not limited to time, expenses, supplies, and labor, and ensures pre-determined financial margins and/or clinical outcomes are achieved.
• Communicates respectfully and effectively with office support staff to promote optimal scheduling efficiency and productivity; adapts to schedule changes with a positive and flexible attitude and provides clinical coverage for other NPs, including contact by telephone or providing visits when needed.
• Supports other team members through collaboration on complex cases.
• Promotes patient relations through confidentiality, privacy, and dignity; provides services in a prompt and courteous manner with care and respect for each patients individual needs.
• Maintains a high level of professionalism in all communications with internal and external contacts, responding promptly and professionally to all concerns, questions, and deadlines.
• Models and promotes geriatric care philosophies and articulates and promotes the EverCare vision, mission, and values locally, statewide, and nationally, when appropriate.
• Adheres to the EverCare Code of Conduct, policies, procedures, protocols, and processes and all regulatory and legal requirements.
• Adheres to the EverCare standards to care for every person, every time, 100% of the time.

Qualifications:

• Current licensure as a Nurse Practitioner in the state where serving, maintained in accordance with applicable laws and regulations, with practice within the specified scope; current DEA registration and national board certification (e.g., AANP or ANCC) as an Adult-Gerontology Primary Care NP (AGPCNP), Adult-Gerontology Acute Care NP, Family NP, or Gerontological NP required.
• Masters degree or Doctorate in Nursing with advanced skills in physical assessment.
• Minimum of three years of clinical nursing experience and/or at least one year of post-graduate clinical NP experience; experience in geriatrics, primary care, home-based primary care, skilled nursing, or palliative care strongly preferred.
• Gerontological specialty certification (e.g., GS-C) preferred.
• Understanding of value-based care, accountable care organizations (ACOs), Medicare care management and wellness programs (CCM, TCM, AWV), quality measures, risk adjustment, and population health principles preferred; willingness to develop proficiency required.
• Highly skilled in advanced nursing practice with a demonstrated ability to assess and respond to the needs of medically complex older adults and their families/caregivers; comfort leading goals-of-care and end-of-life conversations required.
• Understanding of performance improvement with the ability to communicate and operationalize performance improvement initiatives at the departmental and organizational level required.
• Ability to effectively use technology such as cell phones, telehealth platforms, and the electronic medical record (EMR) in support of management and clinical operations.
• Excellent interpersonal skills, sound judgment, effective organizational, prioritization, and follow-through skills, attention to detail, tact, dependability, emotional intelligence, the ability to maintain confidentiality, and the ability to promote positive, constructive relationships with communication and collaboration at all levels required.
• Ability to prioritize multiple demands; demonstrates integrity and flexibility and participates actively in change and quality improvement initiatives.
• Must be able to read, write, and speak English fluently and be able to communicate orally and in writing in internal and external relationships for all essential job functions.
• The physical demands of the position include: vision, effective speech and hearing for extensive telephone contact; repetitive motion; traveling; driving or riding in a motor vehicle; standing, sitting, walking, bending, reaching, and stretching; lifting up to forty-five (45) pounds unassisted and the ability to assist in lifting patients using appropriate lifting techniques and/or devices.
• Proof of current tuberculin testing required.