OverviewBrief summary of purpose:Manages a primary care panel of participants and provides continuity primary health care to PACE participants that reside in the community or long-term care setting with a focus on goal oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant's goals of care. Works in close collaboration with all members of the PACE Interdisciplinary Team.
Establishes realistic goals and helps develop and manage individualized plans of care with the IDT team for program participants.
Provides primary health care to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a participant-focused manner focusing on what matters most.
Works in close collaboration with the program's interdisciplinary team to establish realistic goals and care plans and develop and manage individualized plans of care for program participants.
ResponsibilitiesP
rimary Job Responsibilities (include duties that represent 5% or more of employee's time)- Performs post enrollment visits, biannual exams of participants and appropriately identifies and documents problems/issues in medical records
- Evaluates episodic illnesses and issues appropriate diagnostic and therapeutic orders
- Collaborates with physicians and other interdisciplinary team members to manage episodic and chronic medical needs of participants
- Addresses and documents Advance Directives/MOLST discussion for participants a minimum of annually and when a change in participant condition occurs
- Performs diagnostic, therapeutic and nursing intervention as indicated
- Provides continuity in monitoring of chronic, stable illnesses
- Implements the participant plan of care in a safe and effective manner
- Participates in interdisciplinary team meetings
- Evaluates effectiveness of previously implemented treatment
- Conducts home and nursing home visits as indicated
- Maintains accurate documentation and coding of all services provided according to professional standards
- Identifies utilization and service delivery problems and participates in identifying a resolution
- Identifies grievances and brings forward to leadership
- Participates in quality assessment activities including but not limited to record reviews, outcome measurement and review/revision of policies and procedures
- Provides education and training to participants, caregivers and staff in relevant topics
- Acts a resource to program staff and participates in defining care standards and practices
- Serves on appropriate committees, participates in all site and provider staff meetings including behavioral rounds and psychiatric rounds as indicated.
- Enhances personal professional growth and self-development through participation in professional activities including educational programs, current literature, in-service programs, trainings and workshops.
- Maintains BLS certification and professional certification as appropriate.
- May be asked to perform other duties that align with Fallon Health's mission, including but not limited to participation on clinical committees, providing education, quality initiatives and/or other activities.
QualificationsEducation: Master's degree required. Graduate of an accredited Nurse Practioners program
License/Certifications:- Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing.
- Driving your personal motor vehicle is an essential job function of this position and the following requirements apply:
- Must possess a valid drivers' license
- Must attest to no disqualifiers per Driver Safety Policy
- Must possess and provide proof of minimal state required auto insurance
- Must have reliable transportation
Experience: - One to three years of Nurse Practitioner experience preferred with at least one year of experience in geriatric care.
- Experience working in a healthcare setting as a member of a professional clinical team.
- Experience with care coordination.
- Other: Satisfactory Criminal Offender Record Information (CORI) results
Pay Range Disclosure:- In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is budgeted between $150,000 - $170,000 per year which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.
#P01
