Position Summary: 

Under the general supervision of the Health Services Manager, the Nurse Practitioner (NP) position is responsible for managing member care through collaboration with primary physicians to provide advanced assessment, diagnosis and management or oversight of acute and chronic illness and primary health care. 

For the In Focus program, these responsibilities are conducted for health plan members living in skilled nursing facilities and the NP will provide practice support and collaborate closely with the staff of skilled nursing facilities, clinic staff and partnership teams to effectively manage care for the member.

Duties and Responsibilities:

1.      Primary Health Care / Medical Management (45%)

a.      Provide primary health care to health plan members in their homes, in group homes and nursing homes by providing advanced assessment, diagnosis and management or oversight of acute and chronic illness.  This includes assessing and prescribing medications, ordering procedure and laboratory and diagnostic testing, and conducting physical examinations as indicated.

b.      Provide diagnosis and management of acute and chronic illness.

c.      Collaborate with internal and external resources, including nursing homes, specialists, home health agencies and other disciplines, as necessary to meet the health care needs of the member.

d.      Empower each health plan member to direct his/her own medical/psycho/social care as independently as possible

e.      Participate in interdisciplinary team meetings to provide health information and updates regarding participants in the development of the care plan.

f.        Collaborate with the primary care physician to incorporate his/her suggestions into the Plan of Care

g.      Communicate with the member and with the member’s formal and informal support network as necessary, sharing information with the interdisciplinary team and reviewing and evaluating member outcomes.

2.      Care Management/ Utilization Management (30%):

a.      Collaborate with the Health Plan team to coordinate resources and facilitate procurement of services to meet participant needs

b.      Provide inpatient case management by being the primary liaison with hospital staff in communicating member needs, identifying outcomes in collaboration with inpatient staff, and facilitating discharge planning with other team members as indicated per protocols.

c.      In collaboration with primary care physician and/or care team, provide authorization for specialty care, rehabilitation, psychological services, evaluation or treatment.

d.      Assume leadership role in collaborating with appropriate providers prior to, during, and at discharge from inpatient settings, sub-acute care settings, and short-term skilled nursing homes, and nursing homes

e.      Participate in utilization management activities as assigned

f.        Ensure program efficacy through cost analysis and resource utilization

g.      Share in responsibility for cost-effective and appropriate utilization of health care resources

h.      Monitor utilization of health care services covered by plan

i.        Serve as the primary liaison between the team, the member, and the Primary Care Physician

3.      Education/Outreach (10%):

a.      Provide education to participants and families to ensure informed decision-making regarding their health status and consequences of those decisions

b.      Serve as a clinical expert to the team by providing both formal and informal education and consultation to staff

c.      Provide participant/family education surrounding health maintenance, prevention, illness, medications and other relevant topics based on individual need

d.      Serve as a community education and ambassador regarding the Fidelis programs

e.      Participate in the education seminars for prospective members to recruit new members to the health plan

4.      Quality Assurance/Improvement and Research (5%):

a.      Participate in Quality Improvement studies and agency activities, applying results to clinical programs

b.      Incorporate outcome-based decision-making into practice based on Quality Improvement results

c.      Support the planning of and participate in clinical research as approved by Fidelis

d.      Serve as a preceptor/mentor for graduate students involved in research projects

5.      Other (10%):

a.      Attend appropriate external meetings, groups. Organizations and conferences to promote continuity of services and to promote personal professional development and to maintain professional practice requirements.

b.      Accurately complete all necessary paperwork, such as enrollments, health assessments, statistical records, medical records, and other documentation in the required time frames.

c.      Attend all required in-service training and meet all required health screening obligations

d.      Assist in program development such as development of an information system; peer support; forums for participants; performance indicators for providers and development of educational materials

e.      Participate in forwarding the mission and goals of Fidelis

f.        Participate in and take responsibility for own learning, seeking feedback on performance and actively participating in self and peer performance appraisal

g.      Maintain participant and staff confidentiality at all times

h.      Practice in a manner congruent with ANA Code of Ethics, ANA Scope and Standards of Advanced Practice Nursing

i.        Provide back-up coverage for other nursing personnel and participate in being on-call as assigned

j.         Take responsibility for understanding and performing job in accordance with XX XX compliance standards

k.      Perform other duties as assigned

Qualifications:

1.        Master’s Degree in Nursing required

2.        Possession of Drug Enforcement Administration (DEA) registrations (or eligibility for) required; current and valid DEA number for prescription purposes required

3.        Possession of a licensure or eligibility for licensure in the state in which you will practice as a Registered Nurse, Advance Practice Nurse Prescriber (APNP) licensure, and national NP certification in geriatrics, adult or family practice required

4.        Knowledge and skill in advanced physical assessment required

5.        Knowledge of the human aging process and sufficient knowledge base regarding issues of geriatric nursing required

6.        Experience as a Registered Nurse or Nurse Practitioner preferred

7.        Geriatric experience preferred

8.        Experience in a home care setting preferred

9.        Effective judgment, problem solving, and cognitive skills required

10.    Effective leadership. Organizational, negotiation, conflict resolution and decision-making skills required

11.    Effective interpersonal skills required

12.    Effective oral and written communication skills required

13.    Basic keyboarding skills required

14.    Ability to develop patient education materials as well as in providing education to individuals and groups required

15.    Ability to work well in an interdisciplinary team environment required

16.    Ability to enter data into Prime computer system required

17.    Ability to function with a high degree of independence along with the ability to effectively collaborate with a variety of staff, both internal and external required

18.    Ability to function effect6ively in a fast-paced and changing environment with multiple priorities and objectives required

19.    Ability to effect collaborative alliances and promote teamwork required

20.    Ability to ensure a high level of participant satisfaction required

21.    Ability to develop and maintain effective working relationships required

22.    Ability to present a positive self and organizational image to outside parties required

23.    Ability to lift up to 25 pounds required

24.    Ability to tolerate moderate physical effort, including occasional walking, standing, stooping, moving, squatting, bending, twisting, and/or reaching required

25.    commitment to providing excellent customer service required

26.    Possession of (or ability to obtain) a valid driver’s license in good standing, in the state in which you will practice required

Travel:

Position may require up to 75% local travel.