Position: Nurse Practitioner

Locations (we have openings in each location):

• Queens -Ridgewood
• Brooklyn - Rockaway
• Bronx

Schedule: Monday - Friday, 8:30 am - 5:00 pm (1 hour lunch)
Pay: $68-$72 hourly
Positions: 3

JOB PURPOSE:

The Nurse Practitioner will work in collaboration with contracted community primary care physicians (CPCP) to ensure proper oversight and coordination of participant care with the Interdisciplinary Team. The NP will work with the community physician to coordinate and support the participant's functional, clinical, and psychosocial needs, with an emphasis on independence and wellness. This role will serve as the liaison between the participant, the community physician, and the plan staff to develop and implement the plan of care, including person-centered goal development, communicating changes in the participant's condition, and facilitating primary care preventative services.

JOB RESPONSIBILITIES:

• Assigned a PACE site to see all participants.
• Perform annual wellness assessments on all assigned site participants, reflecting an understanding of the complexity and multiple comorbidities of the frail and/or elderly.
• Provide urgent care services to participants and facilitate same-day access.
• Assess and manage participants with acute changes in condition in a timely manner.
• Assess participants upon return from the hospital/Emergency Department within 5 days, including medication and treatment plan reconciliation and coordination with the participant's CPPCP and IDT members to ensure timely transition of care follow-up visits.
• Review patient's past medical history at least every 6 months and formulate a comprehensive diagnostic list of current and past medical conditions.
• Ensure all documentation is complete and accurate, and specific diagnosis codes are documented in the clinical platform and as encounter data as required.
• Participate in clinical documentation improvement activities to accurately capture the burden of illness of our participants and appropriate risk adjustment.
• Review participant's current symptoms and exacerbation of problems, identifying active diagnoses and chronic conditions for Care Management and medical management of treatment and interventions.
• Co-manage the highest risk subset of participants with the PCPs and communicate findings of assessments to inform Participant's PCP of potential gaps in care.
• Attend and participate in Interdisciplinary team (IDT) meetings, representing CPCP when unavailable or delegating the role to the NP.
• Communicate with IDT team or other Plan designees in accordance with policies and procedures.
• Participate in complex care management and educate participants and their families and staff on topics such as disease processes, medication adherence, and self-management promotion.
• Comply with all HIPAA regulations and maintain the security of Protected Health Information.
• Conduct home visits as needed.
• Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants.
• Supervise the home care services arranged/provided for the community PCP participants.
• Ensure that care coordinated by the CHN is appropriate and meets patient needs, including scheduling, plan of care development, and overseeing clinical outcomes.
• Provide emergency coverage for PACE center primary care providers as needed.
• Participate in on-call rotation as part of the job duties.
• Only act within the scope of the individual's authority to practice.
• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
• Perform other duties as assigned.

QUALIFICATIONS:

• Education: Graduated from a nurse practitioner education program acceptable to NYSED or certified as a nurse practitioner by a national certifying organization acceptable to NYSED.
• Experience:
  • Minimum of two (2) years in clinical nursing practice in-home care, care management, or related field required.
  • Minimum of one (1) year of experience working with a frail or elderly population or appropriate training from the PACE organization upon hiring.
  • Effective oral and written communication and interpersonal skills required.
  • High-level analytical and research skills.
  • Ability to manage multiple projects and meet project deadlines.
  • Basic Computer Skills in Microsoft Office.
• License:
  • Licensed to practice as a Nurse Practitioner in NY required.
  • DEA Certification required.
  • AANP or ANCC Board Certification required.
• Additional Requirements:
  • Legally authorized to practice in the State in which the healthcare professional will perform the function.
  • Medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.
  • Must have a Medicaid Provider ID and a Medicare Provider ID in good standing.