Nurse Practitioner

Job Description Job Description Key Duties and Responsibilities Assessment of patients to identify needs for services and support such as: DME and supplies, acute medical services, behavioral health services, HCBS and primary or specialty care Assist patient and their families/caregivers in identifying goals or care, family support system, environmental, cultural, and linguistic needs for the patient care plan. Complete appropriate assessment within contractual timelines Managing a complex caseload of patients. The performance standard is at least 260 required visits per months Provide primary care services in a collaborative environment for frail and elderly patients in a long-term care setting Provide primary care that will focus assessment, health management, education, advocacy, and prevention Communicate assessment outcomes with patients, PCP, and key service providers Ensure appropriate utilization and consistent application of the benefits Serve as member advocate and facilitator to resolve issues that maybe perceived as barriers to care Collaborate and communicate with other members of the Care Coordinator Team to improve the quality and efficiency of health care delivery Rounding on skilled nursing patient as needed, monthly rounding on custodial patients Through an accurate medical documentation using EMR charting Review and order medications (including IVs), labs, and other diagnostic testing Participate in patient’s IDT’s Available from 7 AM – 7 PM for phone calls from Monday - Friday Participate in on-call for assigned patients (Monday-Friday 7 AM – 7 PM) call for patients without additional compensation which is part of job responsibilities Participate in 1 -2 weekends day calls from 7 AM – 7 PM Will also participate in rotational after hours on-call which may include weekends and holidays, (reimbursement as per company policy), after hours call from 7 PM – 7 AM. Participate in QI program and Peer Review meetings Participate in utilization management program Discussion of advanced care planning Ongoing patient/family communication Proactive communication with case manager and PCPs to keep them apprised of patient care issues Appropriate CPT coding and daily submission of billing forms to office. All chart to be signed within 7 days of visit. Timely completion of all medical records in accordance with facility and other applicable policies. Documents to be completed within 5 days of visit if document is not completed within this time frame will not be counted toward bonus count. Timely completion of: Discharge summary, Annual Wellness Visits. Engagement at Care Management Meetings and Monthly Staffs Meetings POLST completion Perform other duties and responsibilities as assigned Education and Experience Master’s degree with an emphasis in adult/geriatric program Must be Board Certified and have a DEA State certification as adult/geriatric nurse practitioner Current CPR certification Experience in geriatrics and skilled nursing facilities preferred Essential Skills and Abilities Strong background in geriatric and/or internal medicine Furnishing number Demonstrate ability to work independently Manage care experience Thrives in an unstructured, start-up environment. Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members. Creative, flexible, well organized, resourceful, and detail-oriented Excellent judgment in handling confidential and sensitive information Establishing and maintaining cooperative working relationships with others Ability to work across locations and time zones Occasionally require lifting or exert force up to 10 pounds. Licenses/Certifications Must be Board certified and have a DEA State certification as adult/geriatric nurse practitioner Current CPR certification Core Competencies Instills trust Customer focus Manages ambiguity Collaborates Drives results