The Community Nurse Practitioner Supervisor (CNPS) will work in collaboration with contracted community primary care physicians (CPCP)to ensure proper oversight and coordination of participant care with the Interdisciplinary Team. The CNPS will work with the community physician to coordinate and support the participant’s functional, clinical, and psychosocial needs, with an emphasis on independence and wellness. This role will work as the liaison between the participant, the community physician, and plan staff to develop and implement the plan of care, including person-center goal development, communicating changes in participant condition, and facilitating primary care preventative services.
- Each NP will be assigned a PACE site where they will see community participants as needed. This role will incorporate several critical functions including but not limited to:
- At a minimum, performing annual wellness assessments on all assigned site community participants reflects an understanding of the complexity and multiple comorbidities of the frail and/or elderly. For participants with higher levels of risk, these assessments will be performed more frequently to appropriately address his/her level of need, as described below.
- Assesses and manages participants with acute changes in condition in a timely manner.
- Assesses participants upon return from the hospital/Emergency Department within five days. This includes the reconciliation of medications and treatment plans and coordination with the participant’s CPPCP and IDT members to ensure the timely transition of care follow-up visits.
- Reviews patient’s past medical history at least every six months and formulates a comprehensive and complete diagnostic list of current and past medical conditions using clinical knowledge and judgment and the findings of his/her assessment.
- The NP is responsible for ensuring that all such documentation is complete and accurate, and specific diagnosis codes will be documented in CL’s clinical platform and as encounter data as required.
- Reviews the Participant’s current symptoms, and exacerbation of problems that were previously controlled and identifies active diagnoses and chronic problems or conditions to be used in Care Management and active medical management of treatment and designed interventions.
- Communicates findings of assessments to inform Participant’s PCP of potential gaps in care and coordinates with CPCP on a care plan that will address these gaps.
- Attends and participates in CL’s Interdisciplinary team (IDT) meetings and represents CPCP when he/she is unavailable to attend or delegates the role to the NP.
- Communicates with CL’s IDT team or other CL Plan designees in accordance with CL’s policies and procedures.
- Educates participants and their families and CL staff on such topics as disease processes, medication adherence, and self-management promotion.
- Complies with all HIPPA regulations and maintains security of Protected Health Information.
- As any other PACE provider, will conduct home visits as needed.
- Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants, the care plan must be tailored to the needs of the individual, and all interventions and outcomes must be followed and supervised by the practitioner.
- Supervises the home care services that the CHN arranges/provides for the community PCP participants.
- Responsible to ensure that the care coordinated by the CHN is appropriate and deemed for the patient’s needs, including but not limited to scheduling, plan of care development, and overseeing the clinical outcomes.
- The incumbent will also provide emergency coverage for CL’s PACE center primary care providers as needed
- On-call rotation will be expected as part of the job duties.
- Performs other duties as assigned.
- Graduated from a nurse practitioner education program acceptable to NYSED or certified as a nurse practitioner by a national certifying organization acceptable to NYSED.
- Minimum of two years in clinical nursing practice in-home care, care management, or related field required.
- Effective oral and written communication and interpersonal skills required.
- High-level analytical and research skills.
- Ability to manage multiple projects and meet project deadlines.
- Basic Computer Skills in Microsoft office.
- Licensed to practice as a Nurse Practitioner in NY required
- DEA Certification required
- AANP or ANCC Board Certification required
- Bilingual Preferred