Care Home Matron

Assess patients to identify needs for services and support such as: DME, medical supplies, acute medical services, behavioral health services, Home- and Community Based Services (HCBS), primary care, hospice care, and specialty care
Assist patients and their families/caregivers in identifying goals of care, family support system, environmental, cultural, and linguistic needs for the patient care plan
Complete appropriate assessment within appropriate timelines
Manage a complex caseload of patients
Provide primary care services in a collaborative environment for frail and elderly patients in a long-term care setting
Provide primary care with a focus on assessment, health management, education, advocacy, and prevention
Educate patients and families/caregivers about preventive care strategies, disease management, medication adherence, and lifestyle modifications to promote overall wellness
Communicate assessment outcomes with patients, families/caregivers, PCP, and key service providers
Ensure appropriate utilization and consistent application of benefits and services
Serve as member advocate and facilitator to resolve issues that may be perceived as barriers to care
Collaborate and communicate with other members of the Care Coordination team to improve the quality and efficiency of health care delivery
Round regularly on long-term care patients and as needed
Perform accurate, comprehensive, and timely medical documentation using approved EMR system(s)
Review and prescribe appropriate pharmacologic and non-pharmacologic treatment modalities
Administer and interpret diagnostic tests, screenings, and laboratory results
Participate in patient’s IDT’s
Respond timely to patient-related calls during regular work hours Monday through Friday
Participate in after-hours call for assigned patients (Monday through Friday, 7 AM - 7 PM) without additional compensation as part of job responsibilities
Participate in 1 - 2 weekend days for patient related calls from 7 AM - 7 PM
Participate in rotational evening after-hours call which may include weekends and holidays, (reimbursement as per company policy), from 7 PM - 7 AM.
Participate in QI program and Peer Review meetings
Lead discussions related to advanced care planning, to include completion of POLST form. Review annually and as needed with change in condition
Communicate regularly with patient and family/caregiver to provide updates on care, address questions or concerns, and provide guidance on healthcare decisions, ensuring patients are well-informed and empowered to actively participate in their care plans
Communicate regularly with facility staff to ensure alignment with plan of care and care goals
Communicate proactively with case manager and PCPs to keep them apprised of patient care issues
Provide appropriate CPT coding of each visit and timely submission of billing forms to office daily
Timely completion of all medical records in accordance with facility and other applicable policies. Documentation to be completed within 5 days of visit. Any incomplete documentation within the agreed upon timeframe will not be considered toward bonus count
Timely completion of 602 Form (Physicians Report) in accordance with state regulations
Actively participate and engage in regular team meetings, quality improvement initiatives, and ongoing education to optimize care delivery within ACO LEAD program
Perform other duties and responsibilities as assigned
Education and Experience
Master's degree from accredited Nursing school institution.
State certification as adult/geriatric nurse practitioner preferred.
At least three (3) years’ experience in geriatrics. Long-term care and skilled nursing facilities experience preferred.
Essential Skills and Abilities
Strong background in geriatric and/or internal medicine
Knowledge of long-term care, community resources, and cost-effective alternatives regarding patient care delivery systems
Demonstrated ability to work independently, set priorities and handle multiple tasks with a high level of efficiency
Knowledge of clinical standards of care
Experience in manage care and fee-for-service care
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
Self-starter who can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks
Excellent observational, verbal and written communication skills, problem solving skills, mathematical skills; nursing skills per competency checklist
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 multiple locations
Occasionally require lifting or exert force up to 10 pounds.
Strong computer skills, including basic Microsoft suite and EMR systems
Awareness of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems desired
Licenses/Certifications
Must be Board certified and have a DEA.
State certification as adult/geriatric nurse practitioner.
Current CPR certification
Core Competencies
Drives results
To ensure the health and safety of our workforce while doing our part to protect those around us, CareConnectMD is requiring proof of full COVID vaccination for employees as a condition of employment, subject to legally recognized accommodations.

#J-18808-Ljbffr CareConnectMD