Position : Palliative Care Nurse Practitioner - North New Jersey
Monogram Health is seeking a full-time Palliative Care Nurse Practitioner (NP) to join the team to support our rapid nationwide growth. This Palliative Care NP will be an in-market provider delivering in-home care for a highly complex patient population in their community, including end-of-life patients with CKD / ESRD, diabetes, COPD, and CHF. The Palliative Care NP will support the Market Physician Executive and an interdisciplinary team to provide palliative care, clinical guidance to patients and their families, including pain and symptom management, develop appropriate care plans and document advance directives to ensure patient-centered care.
Your Impact
Palliative Care NPs are quality-driven clinicians who apply their expertise in a managed care, population health context. They also engage in population health management in a sophisticated, outcomes-driven manner that promotes palliative care where clinically appropriate and focuses on patient quality of life, education, and shared-decision making.
They will collaborate with our interdisciplinary Pod teams and field clinicians to enhance care integration and optimize palliative care delivery to complex patients through Monogram Health’s comprehensive polychronic care model.
Highlights & Benefits
- Flexible scheduling
- Opportunity to work in a dynamic, fast-paced and innovative organization that is transforming the delivery of polychronic disease care
- Competitive salary plus company bonus program
- Full benefits including medical, dental, vision and life insurance
- Paid time off and 401(k) with matching contributions
Roles & Responsibilities
Collaborate with the Market Physician Executive and clinical leaders including Market Palliative Care physician to proactively identify patients who qualify for palliative care services and build a patient panelDevelop individualized care plans in collaboration with Market Physician Executive and other clinical leaders including Market Palliative Care physician to ensure patients are placed on appropriate evidence-based interventions and pathwaysProvide compassionate, patient-centric palliative care primarily through in-home visits, with virtual care as needed, to support outcomes and care in alignment with patient’s goalsEvaluate and treat symptoms that may interfere with quality of life, like pain, pruritus, depression, anxiety, insomnia, etc.Collaborate with pharmacists and other clinicians to manage medication panels for complex patientsProvide resources and educate patients and their families on the progression of CKD, ESKD, and related conditions, including treatment options and palliative care principlesHelp families navigate complex medical decisions and improve understanding of prognosis, including advance care planning to discuss values, goals of care, and document patient / family wishes in state AD / POLST formsDeliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction firstSupport patients utilizing our interdisciplinary team, including Palliative Care ChaplainAssist with transition to hospice care as appropriateParticipate in monthly meetings with clinical leadership to drive Program KPIs and support execution of clinical and financial goalsEducate and support team members on palliative care, hospice care, advance directives, symptom assessment, and communicationAs needed in the PODs, conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environmentCounsels and educates patients and families about benefits and programs available to help them live healthier livesDocuments items such as : appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan. Completes all documentation and paperwork in a timely mannerResponsible for the coordination of care with primary care providers, specialists, and appropriate ancillary servicesThis position will not be office-based but will be remote in state in which employed and will need to attend periodic training / meetings outside of that statePrescribe medications, order tests, and collaborate with patient’s Monogram physicianPerform effectively, as reflected by improved patient quality outcomes, which will be measured and reported dailyFacilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testingAssists patients with enrolling to access educational videosParticipates in the integrated care team meetingsMake assessment of patient's health status and develop treatment planImplement a plan consistent with patient’ goals of appropriate plan of careFollow-up and evaluate patient's statusOther duties as assignedMinimum Qualifications
Board certification as a Nurse Practitioner; Masters in NursingBoard certified for appropriate licensure (NP : ANCC / AANP; PA : NCCPA)Current and unrestricted DEA certificateAbility to work without direct supervision and practice autonomouslyMust possess reliable transportation and the ability to travel within the designated region to meet patient needs including in-home and clinic visits as needed. Access to transportation, a valid driver's license, and car insuranceActive state-specific licensure and willingness to become licensed in multiple states as company and patient needs require2+ years working with patients in a palliative care setting; other relevant experience will be consideredPreferred Qualifications
Is certified in ACHPN or CHPNDemonstrated experience in clinical assessment, care plan design, and evaluating patients using evidence-based clinical criteriaStrong communication skills for sensitive conversations about prognosis and end-of life decisions including goals of care discussions and advance care planningProficiency with electronic health record (EHR) systems to document complex case detailsAbout Monogram Health
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.M