Participates in initiatives designed to promote quality of life and optimal health of older persons in the community by integrating concepts of prevention, health maintenance, rehabilitation, and palliation in a culturally appropriate manner. Provides clinical leadership to promote compliance with quality, cost measures, and standards of care. Provides ongoing clinical care, education and mentoring to staff/patient/family. Collaborates with management in the evaluation of clinical outcomes data and analysis of practice patterns.Promotes organizational responses that meet the needs of the population. Manages service delivery of inter-professional and para-professional team members working on an individual case or population of cases. Provides advanced nursing clinical care for patients in accordance with current State and Federal rules and regulations for nurse practitioner scope of practice and national standards of care. Works under general supervision.
Responsibilities and Qualifications
Conducts in home,virtual, and/or telephonic encounters (initial or follow up) to identified clients in accordance with regulatory and practice guidelines. Manages and provides comprehensive advanced nursing care including physical examination, comprehensive history, screening for physical and/or psychological conditions, emergent interventions, pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling and patient education. Establishes a treatment plan based on clinical findings. Determines when further evaluation by collaborating physician, specialist or emergency care is warranted.
Analyzes data on individual and stratified populations of patients with complex needs; assesses conditions such as clinical needs, patient satisfaction, quality of life, and cost-effectiveness. Determines strategies for prevention of complications of the above through risk stratification tools, protocols, and ongoing collaboration with physician and multidisciplinary team.
Manages and provides clinical services in compliance with standards of Patient Centered Medical Home, meaningful use of medical record data, HEDIS and QARR quality of care measurements.
Participates in on call coverage schedule to ensure 24/7 access to practice clinicians.
Documents patient care services in accordance with practice standards. Prepares and maintains accurate patient records, charts, and documents to support sound medical practice and reimbursement for services provided.
Assesses, educates, and improves client and caregiver knowledge of chronic disease, self-care management, and identification of changes in health status through individualized education and inter-professional interventions.
Communicates with internal and external care partners regarding needs of patient or population to ensure interventions occur in a timely and appropriate manner. Intervenes as needed when the care plan is not executed, remediates situation to prevent reoccurrence.
Acts as a subject matter resource to clinical staff in the assessment and treatment of patients/families health problems in case conference.
Performs peer and team member review of work performance including quality of care, clinical documentation, coding and billing practices, communication skills and population surveillance.
Works with multidisciplinary team (e.g., nurses, social workers, physicians, etc.) on a consistent basis in order to provide collaborative care and make recommendations on additional services (home care, community services, etc.) as necessary to ensures quality outcomes.
Maintains and increases professional knowledge though continued education, attendance at in-services/conferences/relevant presentations, membership in professional organizations and select journal readership.
Participates in the ESPRIT Quality and Professional Advisory Committee. The Utilization Management Committee, and any associated workgroups related to development of evidence based clinical models of care, peer education and training, quality improvement, medical record configuration and reporting, maximizing use of clinical decision support system.
Participates in special projects and performs other duties as required.
Licensure: License and current registration to practice as a Registered Professional Nurse in the State of New York required. Certification as a Family, Adult or Geriatric Nurse Practitioner required along with DEA.
Education: Master’s Degree in nursing required.
Experience: Minimum of five years clinical nursing experience including two years as a nurse practitioner in a clinical specialty required. Experience in a community health setting, conducting professional presentations and writing for professional publications preferred. Clinical home care experience or managerial experience preferred. Demonstrated knowledge of Hedis and QARR quality measures, ICD-9 and CPT coding for reimbursement of services required. Bilingual skills may be required, as determined by operational needs.