Last Updated -
BASIC PURPOSE & SCOPE:
Under the direction of the Program Director,and in collaboration with the Medical Director, the Nurse Practitioner is responsible for, but not limited to providing direct primary care, supervision, oversight, and day-to-day management of clinical support services and participant care coordination for Total Senior Care, Inc., as an established Program of the All-inclusive Care for the Elderly (PACE) and licensed managed long term care plan in NY State.
1. Practices within his/her scope as defined by the regulations of New York.
2. Practices in collaboration with physician(s) in accordance with a written practice agreement
3. Performs primary care initial assessment, scheduled reassessments and episodic assessments in accordance with program requirements
4. Educates participants and/or caregivers about preventative care, advanced directives, medical issues, and use of prescribed treatments and medications.
5. Provides appropriate staff supervision and development for program and clinic staff,ensuring that supportive medical record documentation is accurate and timely for care management and utilization review.
6. Oversees clinical care coordination between the Interdisciplinary Team (IDT) and network providers to ensure services remain case-managed by the program across all care settings.
7. Coordinates with Quality Improvement Department to ensure QAPI plan activities relevant to participant care is conducted and ensures all necessary documentation and follow up occur within the time-frames defined by the program/operational policy/procedure.
8. Ensures coordination of subject to call schedule to ensure 24 hour access to care.
9. Enables the facilitation of the IDT process and care plan development, inclusive of practice and consistent protocol development for all services.
10. Regularly informs the IDT of the medical, functional, and psychosocial condition of each participant, remaining alert to pertinent input from team members, participants and caregivers with regard to any changing status or care needs
11. Provides evaluation and treatment of participant’s chronic and acute illness with the primary objective to optimize health outcomes and prevent hospitalization or institutional placement.
12. Discusses care guidelines and conducts patient education as necessary with participants,caregivers and identified Health Care Proxy
13. Discusses advanced directives and facilitates Medical Orders for Life Sustaining Treatment (MOLST) completion with participants and the Health Care Proxy
14. Judiciously,along with IDT, seeks specialty consultation and refers and utilizes provider network specialists based on medical necessity
15. Participates in the development and revision of the participant’s plan of care as a member of the IDT. Integrates the primary care treatment plan into the overall plan of care developed by the IDT. Interacts with other team members to meet emergent and acute needs of participants. Participates in discharge planning and transfers to alternative level sof care.
16. Participates in quality management program activities as identified on the QAPI plan,including internal auditing and peer review.
17. Documents accurate diagnoses and changes in the participant’s condition and details care provided by completing all required PACE documentation and ensuring compliance with Agency, state and federal standards and policies on health care documentation, including required hospital and nursing home documentation, medical oversight and care coordination.
18. Collaborates with other nurse practitioner(s) and physicians to ensure comprehensive and continuous care.
19. Provides acute care inpatient consultations, assuring care coordination throughout inpatient stay and discharge.
20. Maintains clinical privileges at contract facilities as needed.
21. Assists in monitoring the medical care of enrolled members who are hospitalized or treated in out-of-network and out-of-service area facilities, and assists in their transfer to in-network facilities/providers when medically appropriate.
22. Provides periodic on-call coverage, as secondary contact after RN staff, per the medical coverage schedule, also including availability for hospital admissions, clinic hours at the center, nursing home, emergency room, or home visits to avoid unnecessary hospitalization.
The above examples of work may not be a complete statement of all assignments that may be inherent to the position. Other duties may be assigned as deemed necessary and appropriate by the Medical Director, Program Director, or President and CEO.
Job Types: Full-time, Part-time
Completed license needed:
Work from Home:
Relocation Assistance Provided: