Nurse Practitioner

This position is a Nurse Practitioner role providing primary care services to frail and elderly patients in a long-term care setting. You will work collaboratively within an interdisciplinary care coordination team to assess patient needs, develop comprehensive care plans, and manage complex caseloads while focusing on health management, education, advocacy, and prevention.

Clinical Setting

You will provide care in a long-term care environment, rounding regularly on patients and participating in an ACO LEAD program. The role involves managing patients across multiple locations and coordinating with facility staff, case managers, primary care physicians, and other service providers.

Responsibilities

• Assess patients to identify needs for services including 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 families/caregivers in identifying goals of care, family support systems, and environmental, cultural, and linguistic needs for care planning
• Complete appropriate assessments within established timelines
• Manage a complex caseload of patients
• 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
• Communicate assessment outcomes with patients, families/caregivers, primary care physicians, and key service providers
• Ensure appropriate utilization and consistent application of benefits and services
• Serve as member advocate and facilitator to resolve barriers to care
• Collaborate with the Care Coordination team to improve quality and efficiency of health care delivery
• Perform accurate, comprehensive, and timely medical documentation using approved EMR systems
• Review and prescribe appropriate pharmacologic and non-pharmacologic treatment modalities
• Administer and interpret diagnostic tests, screenings, and laboratory results
• Participate in patient interdisciplinary team meetings
• Respond timely to patient-related calls during regular work hours Monday through Friday
• Lead discussions related to advanced care planning, including completion of POLST forms, with annual review and as-needed updates
• Communicate regularly with patients, families/caregivers, facility staff, case managers, and PCPs to provide updates, address concerns, and ensure alignment with care goals
• Provide appropriate CPT coding of each visit and timely submission of billing forms daily
• Complete all medical records within five days of visit in accordance with facility and applicable policies
• Complete 602 Forms (Physicians Report) in accordance with state regulations
• Participate actively in team meetings, quality improvement initiatives, and ongoing education
• Perform other duties and responsibilities as assigned

Schedule and On-Call Duties

• Monday through Friday regular work hours with patient-related call responsibilities
• 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 from 7 PM – 7 AM (reimbursement per company policy)

Required Qualifications

• Master's degree from an accredited nursing school institution
• State certification as adult/geriatric nurse practitioner
• Board certification
• Current DEA registration
• Current CPR certification
• At least three years of experience in geriatrics
• 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 high efficiency
• Knowledge of clinical standards of care
• Experience in managed care and fee-for-service care
• Excellent communication and interpersonal skills with ability to effectively communicate with all levels of management, patients, and family members
• Excellent observational, verbal, and written communication skills, problem-solving skills, and mathematical skills
• Creative, flexible, well-organized, resourceful, and detail-oriented
• Excellent judgment in handling confidential and sensitive information
• Ability to establish and maintain cooperative working relationships
• Ability to work across multiple locations
• Strong computer skills, including basic Microsoft suite and EMR systems
• Ability to occasionally lift or exert force up to 10 pounds

Preferred Qualifications

• Long-term care and skilled nursing facilities experience
• Awareness of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems
• Ability to thrive in an unstructured, start-up environment
• Self-starter who can work independently and collaboratively with initiative and excitement to take on unfamiliar tasks

Conditions of Employment

Proof of full COVID vaccination is required as a condition of employment, subject to legally recognized accommodations.