Job Summary: Apply clinical skills to the management of healthcare for medically complex older adults, working collaboratively with an interdisciplinary team to address participants' medical, emotional, and social well-being.
Duties/Responsibilities
Essential Job Functions:
As a member of the PACE Interdisciplinary team (IDT), the nurse practitioner is responsible for the following:
Preparing and updating a comprehensive Care Plan for participants in conjunction with the IDT that that includes medical, emotional, psychosocial aspects of care
Attentive and responsive to input from other team members, participants, and caregivers as pertains to participant's health, and ongoing communication of important clinical information to the IDT
Each nurse practitioner is responsible for the following:
Comprehensive history and physical for new participants to assist with preparation of a comprehensive Care Plan
Reassessment of participants' medical conditions at least every 6 months as part of the participant semi-annual assessment for updating the Care Plan
Managing a participant's medical care for acute and chronic issues
Reviewing outside clinical information for participants, including specialty clinic appointments, hospitalizations, and nursing home stays
Documenting changes of a participant's condition in the medical record in a timely manner, consistent with documentation policies established by the medical director
Work in the PACE clinic at either of the two PACE centers to see participants as scheduled and as needed
Provide in-home care as needed
Contact and inform caregivers of any medical changes
Return calls from participants, caregivers, and staff, in a courteous and timely manner
Serving as the provider on-call for the on-call nurses on evenings and weekends, and returning calls in a courteous, timely manner
Competencies
Effective communication with patients, caregivers, healthcare professionals, and non-medical colleagues, in a manner that ensures understanding
Foster caring interpersonal connections with participants and their caregivers
Enthusiastic collaboration with colleagues in a team environment
Sensitively navigates complex ethical issues involving participants that may arise
Proactively seeks out ways to improve delivery of care
Serves as a trusted liaison with medical director, nurses, and other healthcare professionals within the program
Seeks to support other members of the team with their roles and responsibilities
Appreciates and learns from the knowledge of others on the team, and shares knowledge in return
Participates in research or investigations related to quality improvement
Creatively proposes and adapts treatment plans with openness to unique circumstances of PACE participants, with a focus on delivering goal-concordant care
Physical Requirements: Prolonged periods of sitting at a desk and working on a computer. Sitting, Standing, Walking, Talking, sitting at a desk, and working on a computer. Must be able to lift fifteen pounds at times. Physical Demands: Sedentary physical activity performing non-strenuous daily activities of an administrative nature.
Stand less than 33% of time on duty.
Walk less than 33% of the time on duty.
Sit between 33% and 66% of time on duty.
Use of hands to finger, handle or feel over 66% of time on duty.
Reach with hands or arms less than 33% of time.
Full ability to talk and hear.
Correctable vision required.
Able to lift/carry up to 30 lbs.
Minimum Educational and General Qualifications:
Nursing Degree from an accredited university, and a graduate of a certified or accredited Nurse Practitioner Program; or Master's Degree in Clinical Nursing and five years nursing experience. Must have a current license as an Advanced Practice Registered Nurse (APRN).
Preferred: Five-to-seven years nursing experience, with three years of experience as Nurse Practitioner.