Location: This role provides in-home care across Ponce, PR.
Schedule: Monday through Friday, 8:00 AM to 5:00 PM, with participation in a paid after-hours on-call rotation.
Work Setting: Nurse Practitioners work as part of a care team and travel to patients' residences or other locations to meet with them. This is not an office-based or clinic-based position.
Description:
Impresiv Health is seeking an Advanced Practice Provider / Nurse Practitioner to join an interdisciplinary care team providing comprehensive, value-based care to patients with chronic kidney disease (CKD) stages 3b, 4, 5, and end-stage renal disease (ESRD).
The Advanced Practice Provider will provide direct patient care in patients' homes and other community settings, as well as through telehealth and telephone when appropriate. The provider will collaborate closely with physicians, nurses, social workers, patient navigators, and other members of the care team to support a designated patient panel.
The role focuses on clinical assessment, chronic condition management, medication management, patient and caregiver education, care coordination, psychosocial needs, and comprehensive care planning.
What You Will Do:
- Assume responsibility for an assigned panel of patients in collaboration with the interdisciplinary care team.
- Provide clinical care and support focused on individualized patient-level interventions.
- Complete patient histories and physical examinations.
- Order laboratory and diagnostic testing as appropriate and evaluate test results.
- Educate patients regarding medication use, potential side effects, and treatment plans.
- Prescribe medications as permitted by applicable regulatory authorities.
- Identify and manage patients' clinical conditions and psychosocial care needs.
- Perform structured patient assessments and develop and implement comprehensive care plans.
- Educate patients and caregivers regarding clinical conditions and treatment plans.
- Participate in regular interdisciplinary care team huddles.
- Determine when consultation with medical, surgical, and/or behavioral health specialists is appropriate.
- Coordinate and facilitate care across multiple settings, including emergency departments, hospitals, skilled nursing facilities, home health agencies, hospice organizations, and community-based organizations.
- Provide after-hours telephonic support as required through the on-call rotation.
- Document patient encounters accurately and in a timely manner.
- Assist with the development, implementation, and improvement of clinical protocols and care guidelines.
- Support initiatives focused on patient engagement, patient experience, quality of life, chronic condition documentation, quality measures, clinical outcomes, and reduction of unnecessary medical utilization.
- Maintain confidentiality of all patient-sensitive information.
- Communicate effectively with care team members and partner clinicians regarding patient needs, testing, and treatment.
- Support fellow care team members and contribute to a collaborative team environment.
- Participate in continuous quality improvement efforts.
- Adhere to organizational policies and procedures.
You Will Be Successful If:
- You are self-motivated and able to perform your responsibilities according to established operating procedures.
- You are comfortable providing care in patients' homes and other community-based environments.
- You can work effectively as part of an interdisciplinary care team.
- You communicate effectively with patients, caregivers, clinicians, and other care team members both in person and by telephone.
- You can develop and maintain inclusive and equitable relationships with patients, caregivers, and colleagues.
- You are comfortable managing patients with complex clinical and psychosocial needs.
- You can coordinate care across hospitals, skilled nursing facilities, home health agencies, hospice organizations, specialists, and community resources.
- You maintain accurate and timely clinical documentation.
- You are able to travel throughout the Aguadilla area to provide in-home patient care.
What You Will Bring:
- Current Advanced Practice Nurse (APN) licensure or eligibility to practice in Puerto Rico.
- Bilingual English and Spanish communication skills, both verbal and written.
- Ability to meet required clinician credentialing standards, including successful completion of a background check.
- Consistent access to a vehicle.
- Active driver's license.
- Verifiable good driving record and automobile insurance.
- Ability and willingness to travel to patient homes.
- Experience working with community resources and individuals from diverse backgrounds.
- Comfort interacting with patients and care teams both telephonically and in person.
Preferred Qualifications:
- Experience managing significantly complex patients in hospital environments.
- Experience with chronic kidney disease, end-stage kidney disease, and/or patients receiving dialysis.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do: provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That’s Impresiv!