Nurse Practitioner

Key Duties and Responsibilities

• Conduct comprehensive annual wellness evaluations for traditional Medicare beneficiaries enrolled in the ACO REACH program, focusing on elderly and vulnerable individuals residing in disadvantaged areas.
• Collaborate with a multidisciplinary team to develop individualized care plans based on assessment findings, patient goals, and medical history.
• Perform thorough physical assessments, including reviewing medical histories, conducting physical examinations, and assessing mental health status.
• Administer and interpret diagnostic tests, screenings, and laboratory results to identify potential health issues or risks.
• Educate patients and their families about preventive care strategies, disease management, medication adherence, and lifestyle modifications to promote overall wellness.
• Address patients' concerns, answer questions, and provide guidance on healthcare decisions, ensuring patients are well-informed and empowered to actively participate in their care plans.
• Utilize the ACO REACH program's tools and resources to enhance care quality, coordination, and accessibility, while maintaining the integrity of traditional Medicare features and flexibilities.
• Collaborate with primary care physicians, specialists, social workers, and other healthcare professionals to ensure seamless communication and coordination of care for each patient.
• Document evaluations, assessments, interventions, and care plans accurately and comprehensively in the electronic health record system.
• Continuously stay informed about geriatric best practices, evidence-based guidelines, and relevant healthcare policies to provide the highest standard of care.
• Participate in regular team meetings, quality improvement initiatives, and ongoing education to optimize care delivery within the ACO REACH program.

Education and Experience

• Master's degree with a minimum of one (1) year Nurse Practitioner experience (required) and a minimum of one (1) year hospice or palliative care experience (preferred).
• Must be Board Certified and have a DEA
• State certification as adult/geriatric nurse practitioner
• Current CPR certification
• Experience in geriatrics and skilled nursing facilities preferred
• Certification in a specialist area preferred; (e. g. Hospice and Palliative Nursing (CHPN), or Geriatrics)
• Excellent observation, verbal and written communication skill, problem solving skills, mathematical skills; nursing skills per competency checklist.
• Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.

Essential Skills and Abilities

• Thrives in an unstructured, start-up environment.
• Self-starter that can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks.
• Advanced knowledge of word processing, graphic presentation and computer software related to specific tasks
• Demonstrated excellent computer and word processing skills with special emphasis on calendaring, presentation, and spreadsheet capabilities
• Working knowledge of company policies, procedures, and operations
• Excellent composition, grammar, and business language skills
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members.
• Creative, flexible, well organized, resourceful, and detail-oriented
• Excellent judgment in handling confidential and sensitive information
• Ability to work independently, set priorities and handle multiple tasks with a high level of efficiency
• Establishing and maintaining cooperative working relationships with others
• Ability to work across locations and time zones

Licenses/Certifications

Core Competencies

• Instills trust
• Customer focus
• Manages ambiguity
• Collaborates
• Drives results