Care@Home is designed to provide in-home patient care to our most complex patients living with multiple chronic conditions. The Field Based Nurse Practitioner or Physician Assistant will provide high quality, evidenced based in-home patient care to complex and high-risk patients with the primary goal and objectives of providing best-in-class patient care, reducing avoidable hospitalizations, and decreasing unnecessary emergency department utilization. As a member of the program care team, the Nurse Practitioner (NP), in collaboration with a supervising physician, will be responsible for delivering effective clinical services in the home and/or skilled nursing facility or long-term care facility depending on where the patient is in the continuum of care.Job Responsibilities/Duties
- Conducts face-to-face medical visits to patients for routine visits, acute illness, and post-acute discharge for patients with complex medical conditions.
- Completes a comprehensive health assessment to identify all active and chronic conditions, as well as determine all physical, mental and social needs present at the time of the visit.
- Orders appropriate lab tests and diagnostic procedures and interpret results to aid in health promotion and accurate diagnosis and treatment of illnesses.
- Perform timely and accurate documentation of patients' medical information and all activity related to patient care in electronic medical record system.
- Appropriately assigns the correct coding for acute and chronic conditions. Complete full and appropriate documentation to reflect the services provided in accordance with company policies and procedures.
- Communicates, by phone, in person, in writing or electronically with PCPs and specialists in order to provide comprehensive care or to make referrals, as necessary. Consults with supervising physician as appropriate.
- Participates in On-Call program which may include after-hours, weekend and holiday calls and visitations.
- Provide feedback for program development. Participates in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of service delivery as required.
Minimum Education: Graduate of an accredited Masters Degree in Nursing (MSN) program.
Minimum Experience: Two or more (2+) years of post-graduate experience working as a Nurse Practitioner in an Adult, Family, Internal Medicine, Geriatric, Palliative or Hospice setting. One or more (1+) years of nursing experience in Mental Health, Behavioral Health, Psychiatry or similar.
Req. Certification/Licensure: Board Certified through the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC) or American Academy Physician Assistant (AAPA).