PCP Nurse PractitionerJOB SUMMARY
Delivering primary care and continuous healthcare services to PACE participants, utilizing the knowledge and skills required to assess, plan, and provide care in alignment with PACE Program standards. Works closely with the clinical care team to conduct assessments, reassessments, develop care plans, and deliver comprehensive primary care.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Provide high-quality primary care with a strong focus on individualized evaluation, starting with a comprehensive history and physical exam, rather than defaulting to broad diagnostic testing panels.
- Collaborate closely with the IDT before referring participants to specialists, ensuring referrals are necessary and that continuity of care is maintained.
- Collaborate with the Medical Director to manage specialist referrals, initiate appropriate treatment prior to referral when indicated, review specialist notes promptly, and develop and communicate participant care plans that incorporate clinical judgment and consult findings to ensure comprehensive care.
- Manage and monitor all of your participants' medications, aiming to exceed expectations in medication reconciliation, and medication interactions. This can be done in conjunction with the Medical Director and our collaborating Pharmacist vendor.
- Stay actively informed of participant status during hospitalizations and facility stays, providing appropriate guidance to ensure safe transitions and care continuity.
- Assume shared responsibility for all participants in the center, regardless of individual assignment, supporting the IDT model of team-based care.
- Participate in and contribute to daily IDT meetings, offering clinical insights and collaborating on participant-centered care plans.
- Ensure accurate, timely completion of all participant assessments and documentation in compliance with policy, regulatory, and quality standards.
- Review and respond to labs, imaging, and consults in a timely manner, incorporating findings into ongoing care plans and communicating changes with the IDT.
- Educate participants and caregivers on self-care strategies, medication use, and wellness practices, empowering them to participate in their own care.
- Use the Emergency Department judiciously, prioritizing PACE resources unless symptoms are potentially life-threatening.
- Accurately document diagnoses with attention to proper coding practices, supporting risk adjustment and quality reporting metrics.
- Provide coverage for the 24/7 on-call rotation, addressing participant needs promptly and ensuring proper hand-offs and communication.
- Contribute to discharge planning, supporting smooth transitions across care settings.
- Assist with staff training and mentoring, contributing to clinical policy development and best practice implementation.
Participate in ongoing performance and quality improvement initiatives. - Demonstrate flexibility by stepping into other roles, as allowed by licensure and experience, when needed to support the team.
- Maintain and report clinical resource needs to the Medical Director, supporting effective operations.
- Consistently uphold all safety, privacy, and compliance standards.
EXPERIENCE AND EDUCATION:
- MD, DO, NP, APRN, or PA
- Each physician shall be licensed or authorized by the New Jersey State Board of Medical Examiners to practice medicine in the State of New Jersey.
- Current State license
- State CDS Certification and DEA Registration
- Board Certified in Geriatrics preferred
- BLS required (must have within 90 days of employment)
- 2 years' experience providing direct patient care (preferred)
- 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring (If applicable for the role).
PRE-EMPLOYMENT REQUIREMENTS:
- Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
- Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
- Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.
*Match begins after one year of employment
Monday- Friday 8am-4:30pm
Monday- Friday 8am-4:30pm
