Nurse Practitioner, Care Management

Medicare NPI Credential required.

Participates in initiatives designed to promote quality of life and optimal health of older persons in the community by integrating concepts of prevention, health maintenance, rehabilitation, and palliation in a culturally appropriate manner. Provides clinical leadership to promote compliance with quality, cost measures, and standards of care. Provides ongoing clinical care, education and mentoring to staff/patient/family. Collaborates with management in the evaluation of clinical outcomes data and analysis of practice patterns. Promotes organizational responses that meet the needs of the population. Manages service delivery of inter-professional and para-professional team members working on an individual case or population of cases. Provides advanced nursing clinical care for patients in accordance with current State and Federal rules and regulations for nurse practitioner scope of practice and national standards of care. Works under general supervision.

• Conducts in home, virtual, and/or telephonic encounters (initial or follow up) to identified clients in accordance with regulatory and practice guidelines.  Manages and provides comprehensive advanced nursing care including physical examination, comprehensive history, screening for physical and/or psychological conditions, emergent interventions, pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling and patient education.  Establishes a treatment plan based on clinical findings. Determines when further evaluation by collaborating physician, specialist or emergency care is warranted.

• Analyzes data on individual and stratified populations of patients with complex needs; assesses conditions such as clinical needs, patient satisfaction, quality of life, and cost-effectiveness.  Determines strategies for prevention of complications of the above through risk stratification tools, protocols, and ongoing collaboration with physician and multidisciplinary team.

• Manages and provides clinical services in compliance with standards of Patient Centered Medical Home, meaningful use of medical record data, HEDIS and QARR quality of care measurements.

• Assesses, educates, and improves client and caregiver knowledge of chronic disease, self-care management, and identification of changes in health status through individualized education and inter-professional interventions.

• Communicates with internal and external care partners regarding needs of patient or population to ensure interventions occur in a timely and appropriate manner.  Intervenes as needed when the care plan is not executed, remediates situation to prevent reoccurrence.

• Acts as a subject matter resource to clinical staff in the assessment and treatment of patients/families health problems in case conference.

• Performs peer and team member review of work performance including quality of care, clinical documentation, coding and billing practices, communication skills and population surveillance.

• Works with multidisciplinary team (e.g., nurses, social workers, physicians, etc.) on a consistent basis in order to provide collaborative care and make recommendations on additional services (home care, community services, etc.) as necessary to ensures quality outcomes.