Nurse Practitioner - ACO Annual Wellness Visits

Summary

The Nurse Practitioner (NP) is a registered professional nurse with advanced graduate education and clinical training who provides comprehensive supportive care services in compliance with the relevant state Nurse Practice Act and under the supervision of a collaborating physician. NP conducts comprehensive annual wellness evaluations for the traditional Medicare beneficiaries enrolled in the ACO program. When directed, NP will provide direct clinical care and clinical management for complex frail patients through the evaluation and assessment of the health history, health promotion, diagnosing medical conditions, management of health problems by directing and developing the plan of care, prescribing medications or treatments, coordinating and collaborating with patients, families and other healthcare practitioner. Under the supervision of a physician, the nurse practitioner visits patients in-person or virtually to provide care where the patient resides (facility, home, assisted living and board & care). This job will require driving and traveling to multiple states.

Key Duties and Responsibilities

• Conduct comprehensive annual wellness evaluations for traditional Medicare beneficiaries enrolled in the ACO program, focusing on elderly and vulnerable individuals residing in disadvantaged areas.
• Collaborate with a multidisciplinary team to develop individualized care plans based on assessment findings, patient goals, and medical history.
• Perform thorough physical assessments, including reviewing medical histories, conducting physical examinations, and assessing mental health status.
• Administer and interpret diagnostic tests, screenings, and laboratory results to identify potential health issues or risks.
• Educate patients and their families about preventive care strategies, disease management, medication adherence, and lifestyle modifications to promote overall wellness.
• Address patients' concerns, answer questions, and provide guidance on healthcare decisions, ensuring patients are well-informed and empowered to actively participate in their care plans.
• Utilize the ACO program's tools and resources to enhance care quality, coordination, and accessibility, while maintaining the integrity of traditional Medicare features and flexibilities.
• Collaborate with primary care physicians, specialists, social workers, and other healthcare professionals to ensure seamless communication and coordination of care for each patient.
• Document evaluations, assessments, interventions, and care plans accurately and comprehensively in the electronic health record system.
• Continuously stay informed about geriatric best practices, evidence-based guidelines, and relevant healthcare policies to provide the highest standard of care.
• Participate in regular team meetings, quality improvement initiatives, and ongoing education to optimize care delivery within the ACO program.
• Conduct regular visits for patients in private homes, assisted living facilities, nursing facilities, board, and care.
• Conduct change of condition or post hospital visit for patients in nursing home, assisted living facility, private homes, and board, and care.

Education, License and Certifications

• Master's degree with a minimum of one (1) year Nurse Practitioner experience (required) and a minimum of one (1) year hospice or palliative care experience (preferred).
• Must be Board Certified and have a DEA.
• State certification as adult/geriatric nurse practitioner. Multiple states preferred.
• Certification in a specialist area preferred; (e.g. Hospice and Palliative Nursing (CHPN), or Geriatrics)
• Current CPR certification
• Experience in geriatrics and skilled nursing facilities preferred.
• Experience using Electronic Medical Record systems (EMR).

Essential Skills and Abilities

• Self-starter with the ability to work independently and collaboratively, prioritize tasks effectively, and take initiative, including tackling unfamiliar challenges with enthusiasm.
• Proficient in computer and word processing applications, with expertise in calendaring, presentations, and spreadsheet management.
• Ability to learn and adapt to new software systems quickly, including the use of multiple Electronic Medical Record (EMR) platforms such as PointClickCare and Chartpath.
• Able to promptly access a workstation to gather necessary information and complete comprehensive assessments accurately and efficiently when EMR access is unavailable.
• Skilled in timely and accurate documentation to ensure compliance and efficient workflow.
• Strong observation, verbal and written communication, problem-solving, and mathematical skills, alongside nursing skills as verified by competency checklists.
• Physically capable of prolonged or considerable walking and standing, lifting and transferring patients, and handling supplies and equipment. Must also perform activities such as reaching, stooping, bending, kneeling, and crouching. Visual and auditory acuity required for nursing tasks.
• Exceptional communication and interpersonal skills to engage effectively with all levels of management, patients, and family members.
• Creative, flexible, well-organized, resourceful, and detail-oriented.
• Demonstrates excellent judgment when handling confidential and sensitive information.
• Willingness and ability to travel and work across various locations and time zones.

Core Competencies

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