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Hiring | Nurse Practitioner | NP | Hiring
Responsibility: Provide and/or coordinate primary clinical care services for assigned high risk members and facilitates supportive care during transitions from acute or sub-acute care setting.
Performance Standards:
* Performs Comprehensive Clinical Assessments in the home setting and develops plan of care utilizing evidence based practice recommendations
* Utilize the Physician Associates PC medical record
* Collaborates with Plan Case Manager to schedule and follow-up home visits to update the care plan.
* Insures safe transition from setting to setting, conducts post discharge assessment within a reasonable time period following the modified Coleman Model.
* Evaluates appropriateness of member transfers for acute inpatient services, prospectively and retrospectively and shares necessary clinical information with collaborating physicians/facilities
* Orders diagnostic services and/or therapeutic procedures as necessary to maintain member health
* Provides, or insures, that annual preventive care services are administered and properly documented in the medical record
* Optimizes pharmacy utilization through review and reconciliation of medication profile and EP formulary especially generic utilization and potential drug-drug or drug-disease interactions
* Works in continuous collaboration with primary care physician
* NP will provide individualized care for the at risk population that would improve care coordination, reduce avoidable utilization of hospitals, improve the health and quality of life of community dwelling Elderplan members.
Hiring | Nurse Practitioner | NP | Hiring