Nurse Practitioner

Freedmen’s Medicine is a hybrid medical practice model that specializes in transitional and in-home patient care for chronically ill patients. To be successful, the Nurse Practitioner requires a comprehensive knowledge of chronic care management to include a comprehensive knowledge of chronic diseases such as chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, behavioral health, and substance abuse disorders. The Nurse Practitioner is expected to be a subject matter expert in all aspects of the transitional care model (TCM) related to care management and coordination, this includes adherence to identified timelines for initial and follow-up actions and services. S/he works in collaboration and partnership with the Medical Director and the Director of Operations (DO) to maximize productivity, maximize billing, meet required deadlines, and ensure that critical patient issues are addressed in a timely manner. PRIMARY RESPONSIBILITIES: Fulfils Freedmen Medicine’s mission to enhance patient’s lives through quality healthcare to those in need while providing appropriate physical, mental, and emotional holistic care. This is a full-time position, Monday through Friday, which requires this position to see between 6-10 patients per day and therefore, requires the applicant to be well organized and proficient at time management. Deliver superior care to an assigned panel of complex patients while contributing to our value-based care model and while meeting or exceeding corporate metrics pertaining to productivity. Provide direct day-to-day primary care, transitional care, and comprehensive health assessments to an assigned patient population in-home, in skilled care facilities and other locations within an assigned geographic area. (Applicable Codes)Responsible for reviewing and approving Health Risk Assessments and ensuring that identified issues are addressed for all patients discharged from hospitals to prevent re-admissions. (Applicable Codes) Reviews and sign off on clinical care plans and participate in hospitalization review of documentation and collaborates with the Medical Director and care management staff in the provision of care. (Applicable Codes) Work with the Medical Director and other key staff to identify and develop policies, procedures and protocols to address issues that arise which affect day-to-day provision of care and care management. In the absence of the Medical Director, the Nurse Practitioner must assume a larger role in direct patient care to include covering additional provider visits, completing additional patient orders and related documentation. (Applicable Codes) Lead multi-disciplinary team meetings in partnership with Medical Director and provide leadership to the clinical and care management teams. When necessary, assume a leadership position in ensuring continuity across all care levels from transition throughout the continuum of care Serve as a patient resource for transitional care information and follow-up care coordination, especially during face-to-face visits. Work with the Medical Director, the Director of Operations and Executive staff to develop and operationalize appropriate protocols to be used in the provision of care management. Work with the Director of Operations and the Executive staff to identify and operationalize appropriate key performance indicators and metrics to be used to assess Care Manager productivity and if issues arise, to work to develop solutions to bring metrics into conformity. Write and complete all clinical notes within 48 hours of provider visit and notes must be imputed into the electronic medical record in order to be considered complete. (Applicable Codes) Must sign and clear all medical documents and orders related to patient care on a daily basis. Must perform monthly medication review and reconciliation on a monthly or quarterly basis as determined by the Medical Director. (Applicable Codes) Must adhere to all federal and state guidelines as it relates to patient safety, to include medication administration and reconciliation. EDUCATION: Must be a Board-Certified Nurse Practitioner with a degree from an accredited nursing school and preferably with experience in chronic care management Must have a valid District of Columbia and Maryland state license and a valid Drug Enforcement Agency (DEA) number Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications required. EXPERIENCE: Minimum of 1-3 years of work experience as a Nurse Practitioner in a healthcare setting involving patients with complex chronic disease conditions preferred. Two (2) years of management or supervision experience preferred. ENVIRONMENTAL/ WORKING CONDITIONS: The Nurse Practitioner is required to work a combination of on-site location and virtually and therefore, will be required to physically be on-site as required. PHYSICAL/ MENTAL DEMANDS: Must possess the cognitive/mental ability and patience to employ language and interactive communication skills while engaging with challenging patients suffering from physical, mental, and substance use disorders. This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve. #J-18808-Ljbffr Freedmen's Medicine