Nurse Practitioner

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