Nurse Practitioner - ProMed Staffing Resources

The Nurse Practitioner Supervisor (NPS) 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 NPS 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 work as the liaison between the participant, the community physician, and the plan staff to develop and implement the plan of care, including person-center goal development, communicating changes in the participant's condition, and facilitating primary care preventative services.
JOB RESPONSIBILITIES:
1.
Each NPS will be assigned a PACE site where they will see all CenterLight's participants.
2.
Supervises and manages Nurse Practitioners assigned to their location and assists with the oversight of other Diagnostic Treatment Center's clinical staff as needed.
3.
Complete direct reports and annual performance appraisals and collaborate with other DTC Managers providing annual performance feedback to the DTC clinical staff as needed.
4.
In the absence of, or at the direction of, the Medical Director, the NPS will represent or serve as the Medical Director role at their location.
5.
At a minimum, perform annual wellness assessments on all assigned site participants and ensure reflects an understanding of the complexity and multiple comorbidities of the frail and/or elderly. For participants with higher levels of risk, these assessments will be performed more frequently to appropriately address his/her level of need, as described below.
6.
Provides urgent care services to participants and facilitates the provision of same-day access. Assesses and manages participants with acute changes in condition in a timely manner.
7.
Assesses participants upon return from the hospital/Emergency Department within 5 days. This includes the reconciliation of medications and treatment plans and coordination with the participant's CPPCP and IDT members to ensure the timely transition of care follow-up visits.
8.
Reviews the patient's past medical history at least every 6 months and formulate a comprehensive and complete diagnostic list of current and past medical conditions using clinical knowledge and judgment and the findings of his/her assessment.
9.
The NPS is responsible for ensuring that all such documentation is complete and accurate, and specific diagnosis codes will be documented in CL's clinical platform and as encounter data as required.
10.
Participates in all clinical documentation improvement activities with the goal being an accurate and full capture of the burden of illness of our participants and appropriate risk adjustment. Provide feedback and counseling to DTC and IDT staff regarding their clinical documentation as needed.
11.
Reviews the Participant's current symptoms and exacerbation of problems that were previously controlled and identifies active diagnoses and chronic problems or conditions to be used in Care Management and active medical management of treatment and designed interventions.
12.
Co-manages the highest risk subset of participants with the PCPs and communicates findings of assessments to inform Participant's PCP of potential gaps in care and coordinates with CPCP on a care plan that will address these gaps.
13.
Attends and participates in CL's Interdisciplinary team (IDT) meetings and represents CPCP when he/she is unavailable to attend or delegates the role to the NP.
14.
Communicates with CL's IDT team or other CL Plan designees in accordance with CL's policies and procedures.
15.
Participates in complex care management and educates participants and their families and CL staff on such topics as disease processes, medication adherence, and self-management promotion.
16.
Complies with all HIPPA regulations and maintains security of Protected Health Information.
17.
As any other PACE provider, will conduct home visits as needed.
18.
Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants; the care plan must be tailored to the needs of the individual, and all interventions and outcomes must be followed and supervised by the practitioner.
19.
Supervises the home care services that the CHN arranges/provides for the community PCP participants.
20.
Responsible for ensuring that the care coordinated by the CHN is appropriate and deemed for the patient's needs, including but not limited to scheduling, plan of care development, and overseeing the clinical outcomes.
21.
The incumbent will also provide emergency coverage for CL's PACE center primary care providers as needed
22.
On-call rotation will be expected as part of the job duties.
23.
Performs other duties as assigned.