Geriatrics Nurse Practitioner

Seeking a Transitional Care Nurse Practitioner to d eliver high-touch, high-quality care to high-risk patients within their homes in the Rockford, IL area.

Details / Responsibilities :

• Full-time, Mon - Fri, 8am-5pm
• Deliver high-touch, high-quality care to the highest risk patients within their homes
• This role is supported by a scribe / medical assistant, nurse, social worker, and other resources.
• NPs make 6-7 visits daily in a defined territory and collaborate continuously with other team members for care coordination and all other needs.
• APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up.
• Provide post-discharge support according to defined pathways within the patient's home
• Develop care plans and individualize goals of care with patient, their families, and their providers
• Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
• Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
• Structure and prioritize scheduling based on clinical complexity for both new and routine patients
• Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
• Provide after-hours and weekend call support, shared with other in state providers
• Facilitate and conduct goals of care and advance care planning discussions with patients and families
• Assess and evaluate family / caregiver needs and limitations
• Teach patients, caregivers, and others about their health conditions
• Accurate and timely documentation of patient encounters in electronic medical records
• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
• Other duties, as assigned

Qualifications :

Compensation & Benefits :

The Community :

Nestled along a scenic river in northern Illinois, this city offers a unique blend of affordability, cultural charm, and natural beauty, making it an ideal place to live, work, and explore. Residents enjoy access to expansive parks, botanical gardens, a vibrant arts scene, and family-friendly attractions all without the high cost or congestion of larger urban centers. The area features a strong sense of community, diverse neighborhoods, and easy living, with a variety of local shops, restaurants, and entertainment options. Conveniently located about 90 miles from Chicago and 70 miles from Madison, it provides quick access to major metro areas while maintaining its own identity and pace. Whether you're looking to raise a family, start a career, or enjoy a more relaxed lifestyle with city perks nearby, this region offers a welcoming and well-rounded home base.

APPLY NOW or TEXT Job and email address to 636 - 628 - 2412.

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