Northeast FL House Calls; Duval, Clay, Baker, St. Johns, Nassau

The Nurse Practitioner is responsible, as part of the patient care team, for the overall patient care management process. An advocate for the patient, the Nurse Practitioner will provide total care for the patients assigned in collaboration with the physician of record and patient care team. The Nurse Practitioner will communicate and manage the patients' care across all care providers, family, and caregivers.

The Nurse Practitioner will ensure that timely, patient-centered, appropriate evidence-based medicine is provided. The Nurse Practitioner will assist in addressing outstanding Quality Measures and HCCs as applicable to meet or exceed all quality goals. The Nurse Practitioner will be responsible for ongoing communication with the Primary Care Provider to ensure continuity and coordination of care. The Nurse Practitioner will complete all documentation and billing in a timely manner, per protocol.

Responsible for other duties as assigned.

• Is responsible for the total care of all assigned patients in collaboration with the community-based physician/provider and patient care team.
• Is responsible for patient assessments and care planning, risk management plan development, addressing quality measures and HCCs, and providing both maintenance care and acute interventions within their scope of practice.
• Provides services to meet patient needs and prevent unnecessary Emergency Department utilization when appropriate. In home services include but are not limited to: IV hydration/antibiotic therapy, lab draws, nebulizer treatments, EKGs, wound care, and injections, and utilization of mobile diagnostics as indicated.
• Ensures all pertinent and active medical conditions are documented in the electronic medical record in a timely manner, consistent with MPG policy, and in a compliant manner with CMS and other insurance carriers.
• Exhibits strong clinical skills to improve patient care for an aging, adult population; as well as excellent interpersonal relationship skills in interpreting and communicating health care information to the patient, family, and Patient Care Team.
• Provides leadership in the application of the nursing process to client care, organizational processes and/or systems improving outcomes at the program or service level and initiates interdisciplinary projects to improve organizational performance.
• Identifies patients who are appropriate and would benefit from Skilled Nursing/Therapy and initiates the SNF 3 Day Waiver for MACO qualifying patients. Follows all CMS guidelines and ensures patient is admitted to a qualifying SNF. Completes all required documentation and works with SNF Case Manager and other members of the health care team to ensure continuity and patient safety.
• Accountable for identifying patients needing additional assistance and making referrals to Home Care, Social Services, Behavioral Health, and other available community resources, when needed and appropriate.
• Responsible for direct oversight of assigned Medical Assistant. Works collaboratively with Program Director to establish workflow processes, provisions of ongoing education/training, and employee improvement planning as needed.

This job has no direct supervisory responsibilities but may indirectly oversee assigned Patient Care Specialist.

• Analysis/Problem Assessment - Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.
• Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.
• Compliance - Employee has satisfactory completed employer's required compliance training. Employee is able to demonstrate an understanding of employer's Code of Conduct.
• Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.
• Dependability - Meets commitments,…