PCP Nurse Practitioner

JOB SUMMARY  

Delivering primary care and continuous healthcare services to PACE participants, utilizing the knowledge and skills required to assess, plan, and provide care in alignment with PACE Program standards. Works closely with the clinical care team to conduct assessments, reassessments, develop care plans, and deliver comprehensive primary care. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:  

• Provide high-quality primary care with a strong focus on individualized evaluion, starting with a comprehensive history and physical exam, rher than defaulting to broad diagnostic testing panels.
• Collabore closely with the IDT before referring participants to specialists, ensuring referrals are necessary and th continuity of care is maintained.
• Collabore with the Medical Director to manage specialist referrals, initie approprie trement prior to referral when indiced, review specialist notes promptly, and develop and communice participant care plans th incorpore clinical judgment and consult findings to ensure comprehensive care.
• Manage and monitor all of your participants' medicions, aiming to exceed expections in medicion reconciliion, and medicion interactions. This can be done in conjunction with the Medical Director and our collaboring Pharmacist vendor.
• Stay actively informed of participant stus during hospitalizions and facility stays, providing approprie guidance to ensure safe transitions and care continuity.
• Assume shared responsibility for all participants in the center, regardless of individual assignment, supporting the IDT model of team-based care.
• Participe in and contribute to daily IDT meetings, offering clinical insights and collaboring on participant-centered care plans.
• Ensure accure, timely completion of all participant assessments and documention in compliance with policy, regulory, and quality standards.
• Review and respond to labs, imaging, and consults in a timely manner, incorporing findings into ongoing care plans and communicing changes with the IDT.
• Educe participants and caregivers on self-care stregies, medicion use, and wellness practices, empowering them to participe in their own care.
• Use the Emergency Department judiciously, prioritizing PACE resources unless symptoms are potentially life-threening.
• Accurely document diagnoses with tention to proper coding practices, supporting risk adjustment and quality reporting metrics.
• Provide coverage for the 24/7 on-call rotion, addressing participant needs promptly and ensuring proper hand-offs and communicion.
• Contribute to discharge planning, supporting smooth transitions across care settings.
• Assist with staff training and mentoring, contributing to clinical policy development and best practice implemention.
• Participe in ongoing performance and quality improvement initiives.
• Demonstre flexibility by stepping into other roles, as allowed by licensure and experience, when needed to support the team.
• Maintain and report clinical resource needs to the Medical Director, supporting effective operions.
• Consistently uphold all safety, privacy, and compliance standards.

EXPERIENCE AND EDUCATION: 

• MD, DO, APRN, NP, or PA 
• Current Ste license 
• Ste CDS Certificion and DEA Registrion 
• Board Certified in Gerirics preferred
• BLS required (must have within 90 days of employment)
• 2 years experience providing direct pient care (preferred)
• 1 year of experience working with a frail or elderly populion preferred. If this is not present, training will be provided upon hiring (If applicable for the role).  

PRE-EMPLOYMENT REQUIREMENTS:   

• Must have reliable transportion, a valid driver's license, and the minimum ste required liability auto insurance.   
• Be medically cleared for communicable diseases and have all immunizions up to de before engaging in direct participant contact.   
• Pass a comprehensive criminal background check th may include, but is not limited to, federal and ste Medicare/Medicaid exclusion lists, criminal history, educion verificion, license verificion, reference check, and drug screen.