Post-Acute / Long-Term Care Nurse Practitioner

Key Duties and Responsibilities

• Assess patients to identify needs for services and support such as: 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 their families/caregivers in identifying goals of care, family support system, environmental, cultural, and linguistic needs for the patient care plan
• Complete appropriate assessment within appropriate timelines
• Manage a complex caseload of patients
• Provide primary care services in a collaborative environment for frail and elderly patients in a long-term care setting
• 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 to promote overall wellness
• Communicate assessment outcomes with patients, families/caregivers, PCP, and key service providers
• Ensure appropriate utilization and consistent application of benefits and services
• Serve as member advocate and facilitator to resolve issues that may be perceived as barriers to care
• Collaborate and communicate with other members of the Care Coordination team to improve the quality and efficiency of health care delivery
• Round regularly on long-term care patients and as needed
• Perform accurate, comprehensive, and timely medical documentation using approved EMR system(s)
• Review and prescribe appropriate pharmacologic and non-pharmacologic treatment modalities
• Administer and interpret diagnostic tests, screenings, and laboratory results
• Participate in patient’s IDT’s
• Respond timely to patient-related calls during regular work hours Monday through Friday
• 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, (reimbursement as per company policy), from 7 PM – 7 AM.
• Participate in QI program and Peer Review meetings
• Lead discussions related to advanced care planning, to include completion of POLST form. Review annually and as needed with change in condition
• Communicate regularly with patient and family/caregiver to provide updates on care, address questions or concerns, and provide guidance on healthcare decisions, ensuring patients are well-informed and empowered to actively participate in their care plans
• Communicate regularly with facility staff to ensure alignment with plan of care and care goals
• Communicate proactively with case manager and PCPs to keep them apprised of patient care issues
• Provide appropriate CPT coding of each visit and timely submission of billing forms to office daily
• Timely completion of all medical records in accordance with facility and other applicable policies. Documentation to be completed within 5 days of visit. Any incomplete documentation within the agreed upon timeframe will not be considered toward bonus count
• Timely completion of 602 Form (Physicians Report) in accordance with state regulations
• Actively participate and engage in regular team meetings, quality improvement initiatives, and ongoing education to optimize care delivery within ACO LEAD program
• Partner with ALF facility leadership and community teams on outreach and marketing initiatives to promote awareness of the program and support growth among residents, families, and the surrounding community.
• Provide ongoing education and health-related training to facility staff, residents, and families/caregivers to promote health awareness, preventive care, and effective management of patient needs.
• Perform other duties and responsibilities as assigned

Education and Experience

• Master's degree from accredited Nursing school institution.
• State certification as adult/geriatric nurse practitioner preferred.
• At least three (3) years’ experience in geriatrics. Long-term care and skilled nursing facilities experience preferred.

Essential Skills and Abilities

• 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 a high level of efficiency
• Knowledge of clinical standards of care
• Experience in manage care and fee-for-service care
• Thrives in an unstructured, start-up environment
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members
• Self-starter who can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks
• Excellent observational, verbal and written communication skills, problem solving skills, mathematical skills; nursing skills per competency checklist
• Creative, flexible, well organized, resourceful, and detail-oriented
• Excellent judgment in handling confidential and sensitive information
• Establishing and maintaining cooperative working relationships with others
• Ability to work across multiple locations
• Occasionally require lifting or exert force up to 10 pounds.
• Strong computer skills, including basic Microsoft suite and EMR systems
• Awareness of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems desired

Licenses/Certifications

• Must be Board certified and have a DEA.
• State certification as adult/geriatric nurse practitioner.
• Current CPR certification

Core Competencies

• Instills trust.
• Customer focus
• Manages ambiguity.
• Collaborates

Salary Range

$140,000.00 - $155,000.00 Annually