Job Description

• Provides initial and ongoing participant assessment, care plan development implementation of care plan for participants living in community, congregate, adult home or skilled nursing facility settings.

• Responsible for full assessment of participants including obtaining health records, performing physical and mental evaluations, evaluating diagnostic tests, and reporting findings and identifying status changes.
• Performs complete analysis and assessments of participants including recognizing abnormal findings in testing, exercising clinical judgement and interpreting screenings and other diagnostic tests in accordance with medical standards of care.
• Monitors ongoing and chronic health problems, anticipating needs and in collaboration with physicians, prescribes and adjusts medication within current practice guidelines and notifies appropriate teams.
• Appropriately orders consultations with specialists as indicated, outreaches to consultants to request specific goals, reviews recommendations from consultants, takes action as clinically appropriate, and documents timely.
• Provides ongoing education, counseling and guidance with participants and families including goals of care and participates in family meetings.
• Monitors care and evaluates effectiveness of individual care plans while making appropriate revisions and notifying family and caregivers
• Functions as a member of the interdisciplinary team and participates in development of comprehensive plan of care and ongoing monitoring of participants' health status.
• Participates in clinical administrator on-call rotation.
• Documents in a timely fashion consistent with CMS standards in ASL EMR.
• Travels to participant homes and their congregate homes and/or facilities to help bridge care in the community.

Qualifications

• ANCC Certification
• Current NY State RN License and Advanced Practice Nurse Prescriber License
• Ability to travel to additional facilities as needed

Education:

• Master's degree in nursing with completion of accredited program for Nurse Practitioners