Job Description

Summary

CareConnectMD is seeking a compassionate, experienced Nurse Practitioner to provide patient-centered primary care to older adults in Assisted Living Facilities (ALFs). In this role, you'll build meaningful relationships with residents and their families, manage complex medical needs, and collaborate with facility staff and an interdisciplinary care team to improve health outcomes and quality of life.

This is an opportunity to make a meaningful impact in a growing healthcare environment, with a focus on preventive care, chronic disease management, care coordination, and helping older adults receive the right care at the right time.

Key Duties and Responsibilities

• Assess patients to identify needs for services and support such as: DME, medical supplies, acute medical services, behavioral health services, Home- and Community Based Services (HCBS), primary care, hospice care, and specialty care
• Assist patients and their families/caregivers in identifying goals of care, family support system, environmental, cultural, and linguistic needs for the patient care plan
• Complete appropriate assessment within appropriate timelines
• Manage a complex caseload of patients
• Provide primary care services in a collaborative environment for frail and elderly patients in a long-term care setting
• Provide primary care with a focus on assessment, health management, education, advocacy, and prevention
• Educate patients and families/caregivers about preventive care strategies, disease management, medication adherence, and lifestyle modifications to promote overall wellness
• Communicate assessment outcomes with patients, families/caregivers, PCP, and key service providers
• Ensure appropriate utilization and consistent application of benefits and services
• Serve as member advocate and facilitator to resolve issues that may be perceived as barriers to care
• Collaborate and communicate with other members of the Care Coordination team to improve the quality and efficiency of health care delivery
• Round regularly on long-term care patients and as needed
• Perform accurate, comprehensive, and timely medical documentation using approved EMR system(s)
• Review and prescribe appropriate pharmacologic and non-pharmacologic treatment modalities
• Administer and interpret diagnostic tests, screenings, and laboratory results
• Participate in patient's IDT's
• Respond timely to patient-related calls during regular work hours Monday through Friday
• Participate in after-hours call for assigned patients (Monday through Friday, 7 AM – 7 PM)
• Participate in 1 - 2 weekend days for patient related calls from 7 AM – 7 PM
• Participate in rotational evening after-hours call which may include weekends and holidays, (reimbursement as per company policy), from 7 PM – 7 AM.
• Participate in QI program and Peer Review meetings
• Lead discussions related to advanced care planning, to include completion of POLST form. Review annually and as needed with change in condition
• Communicate regularly with patient and family/caregiver to provide updates on care, address questions or concerns, and provide guidance on healthcare decisions, ensuring patients are well-informed and empowered to actively participate in their care plans
• Communicate regularly with facility staff to ensure alignment with plan of care and care goals
• Communicate proactively with case manager and PCPs to keep them apprised of patient care issues
• Provide appropriate CPT coding of each visit and timely submission of billing forms to office daily
• Timely completion of all medical records in accordance with facility and other applicable policies. Documentation to be completed within 5 days of visit. Any incomplete documentation within the agreed upon timeframe will not be considered toward bonus count
• Timely completion of 602 Form (Physicians Report) in accordance with state regulations
• Actively participate and engage in regular team meetings, quality improvement initiatives, and ongoing education to optimize care delivery within ACO LEAD program
• Partner with ALF facility leadership and community teams on outreach and marketing initiatives to promote awareness of the program and support growth among residents, families, and the surrounding community.
• Provide ongoing education and health-related training to facility staff, residents, and families/caregivers to promote health awareness, preventive care, and effective management of patient needs.
• Perform other duties and responsibilities as assigned

Education and Experience

• Master's degree from accredited Nursing school institution.
• State certification as adult/geriatric nurse practitioner preferred.
• At least three (3) years' experience in geriatrics. Long-term care and skilled nursing facilities experience preferred.

Essential Skills and Abilities

• Strong background in geriatric and/or internal medicine
• Knowledge of long-term care, community resources, and cost-effective alternatives regarding patient care delivery systems
• Demonstrated ability to work independently, set priorities and handle multiple tasks with a high level of efficiency
• Knowledge of clinical standards of care
• Experience in manage care and fee-for-service care
• Thrives in an unstructured, start-up environment
• Excellent communication and interpersonal skills with the ability to effectively communicate with all levels of management, patients, and family members
• Self-starter who can work independently and collaboratively, prioritize tasks and has initiative and excitement to take on unfamiliar tasks
• Excellent observational, verbal and written communication skills, problem solving skills, mathematical skills; nursing skills per competency checklist
• Creative, flexible, well organized, resourceful, and detail-oriented
• Excellent judgment in handling confidential and sensitive information
• Establishing and maintaining cooperative working relationships with others
• Ability to work across multiple locations
• Occasionally require lifting or exert force up to 10 pounds.
• Strong computer skills, including basic Microsoft suite and EMR systems
• Awareness of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems desired

Licenses/Certifications

• Must be Board certified and have a DEA.
• State certification as adult/geriatric nurse practitioner.
• Current CPR certification

Core Competencies

• Instills trust.
• Customer focus
• Manages ambiguity.
• Collaborates