JOB PURPOSE: In collaboration and consultation with physicians, staff RN's and other health care professionals, provides holistic, compassionate care to patients and families and provides care coordination and care management activities on behalf of the PruittHealth Premier Plan. Practices within the context of collaborative management with the physician(s) in diagnosing, managing, and preventing acute and chronic illness and disease, and promoting wellness. D-SNP Nurse Practitioners will visit members in their home as well as conduct telehealth visits for health risk assessments for new and post care transition members. Nurse Practitioners have an advanced nursing practice that includes independent nursing functions based on nursing standards of care and a role in medical management working within a collaborative agreement with a physician(s).

KEY RESPONSIBILITIES:

1. Proven ability to perform comprehensive, adult/geriatric admission history and physical exam

2. Demonstrates ability to identify, diagnose and document episodic, acute and chronic disease in adult

3. Demonstrates ability to recognize conditions, characteristics, and behaviors that place seniors at risk

4. Proven ability to pursue feedback, continuing education and professional development

5. Ability to effectively reconcile medication

6. Demonstrates ability to identify and document the needs of clinically complex patient

7. Work collaboratively with physicians, case managers, social workers, family members, key care givers and any appropriate ancillary medical personnel as appropriate

8. Participates in Quality Assurance Performance Improvement (QAPI) activitie

9. Assesses the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team member

10. Coordinates care as member's transition through different levels of care and care settings, ensures that the ICP is communicated immediately and/or no later than 24 hours to the receiving care setting

Qualifications:

MINIMUM EDUCATION REQUIRED:

Graduate of an accredited Adult or Family Nurse Practitioner Masters Degree program or Physician Assistant Studie

MINIMUM EXPERIENCE REQUIRED:

Minimum 2 years clinical experience as a Nurse Practitioner or Physician Assistant in geriatric, adult or family practice setting. Proven ability to perform comprehensive adult/geriatric physical exams.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:

• Current and unrestricted, RN and NP licensure, or PA licensure in state of practice. Board certification by AANP or ANCC, in Adult, Family Practice and Geriatrics or Adult-Gerontology Primary Care. Current CPR certification

• Active DEA license

• Must have an active national provider number (NPI) and an active Medicare provider number
• Must be eligible to participate in the Medicare program as a provider and registered

ADDITIONAL QUALIFICATIONS: (Preferred qualifications)

Graduate of an accredited Geriatric, Adult or Family Nurse Practitioner Masters Degree program. Previous experience visiting clients in their homes preferred.

KNOWLEDGE, SKILLS, ABILITIES

1. Pertinent Clinical Work Experience which is relevant to population being served.

2. Reviews and interprets the medical and social history of member

3. Interprets laboratory data, recommend appropriate follow-up, reconcile medication

4. Manages both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider

5. Synthesizes information and easily diagnoses and creates a comprehensive plan of care.

6. Complete all regulatory required monthly, quarterly, and/or annual visits and acute visits as needed.

7. Maintain appropriate and compliant documentation within our EMR (electronic medical record) software

8. Ensures all diagnoses are ICD-10 coded accurately and documented appropriately to support the diagnosis at that visit

9. Reviews orders and interventions for appropriateness and response to treatment to identify the most effective plan of care that aligns with the member's needs and wishe

10. Participate in family conferences and provide advanced care planning and education when needed

11. Address any pharmacy recommendations or pharmacist communications regarding member

12. Work together with the care management team to communicate issues identified to care management for follow up and to meet HEDIS/Star Quality measure

13. Practice ethically and in accordance with the Scope and Standards of Practice of their profession and Board Certification

14. Travels between member homes is mandatory

15. Performs other duties as assigned