Job Summary: Apply clinical skills to the management of healthcare for medically complex older adults, working collaboratively with an interdisciplinary team to address participants' medical, emotional, and social well-being.
Duties/Responsibilities
Essential Job Functions:
- As a member of the PACE Interdisciplinary team (IDT), the nurse practitioner is responsible for the following:
- Preparing and updating a comprehensive Care Plan for participants in conjunction with the IDT that that includes medical, emotional, psychosocial aspects of care
- Attentive and responsive to input from other team members, participants, and caregivers as pertains to participant's health, and ongoing communication of important clinical information to the IDT
- Each nurse practitioner is responsible for the following:
- Comprehensive history and physical for new participants to assist with preparation of a comprehensive Care Plan
- Reassessment of participants' medical conditions at least every 6 months as part of the participant semi-annual assessment for updating the Care Plan
- Managing a participant's medical care for acute and chronic issues
- Reviewing outside clinical information for participants, including specialty clinic appointments, hospitalizations, and nursing home stays
- Documenting changes of a participant's condition in the medical record in a timely manner, consistent with documentation policies established by the medical director
- Work in the PACE clinic at either of the two PACE centers to see participants as scheduled and as needed
- Provide in-home care as needed
- Contact and inform caregivers of any medical changes
- Return calls from participants, caregivers, and staff, in a courteous and timely manner
- Serving as the provider on-call for the on-call nurses on evenings and weekends, and returning calls in a courteous, timely manner
Competencies
- Effective communication with patients, caregivers, healthcare professionals, and non-medical colleagues, in a manner that ensures understanding
- Foster caring interpersonal connections with participants and their caregivers
- Enthusiastic collaboration with colleagues in a team environment
- Sensitively navigates complex ethical issues involving participants that may arise
- Proactively seeks out ways to improve delivery of care
- Serves as a trusted liaison with medical director, nurses, and other healthcare professionals within the program
- Seeks to support other members of the team with their roles and responsibilities
- Appreciates and learns from the knowledge of others on the team, and shares knowledge in return
- Participates in research or investigations related to quality improvement
- Creatively proposes and adapts treatment plans with openness to unique circumstances of PACE participants, with a focus on delivering goal-concordant care
Physical Requirements: Prolonged periods of sitting at a desk and working on a computer. Sitting, Standing, Walking, Talking, sitting at a desk, and working on a computer. Must be able to lift fifteen pounds at times. Physical Demands: Sedentary physical activity performing non-strenuous daily activities of an administrative nature.
- Stand less than 33% of time on duty.
- Walk less than 33% of the time on duty.
- Sit between 33% and 66% of time on duty.
- Use of hands to finger, handle or feel over 66% of time on duty.
- Reach with hands or arms less than 33% of time.
- Full ability to talk and hear.
- Correctable vision required.
- Able to lift/carry up to 30 lbs.
Minimum Educational and General Qualifications:
Nursing Degree from an accredited university, and a graduate of a certified or accredited Nurse Practitioner Program; or Master's Degree in Clinical Nursing and five years nursing experience. Must have a current license as an Advanced Practice Registered Nurse (APRN).
Preferred: Five-to-seven years nursing experience, with three years of experience as Nurse Practitioner.