*** THIS POSITION MAY BE ELIGIBLE FOR UP TO A $15,000 SIGN-ON BONUS (restrictions may apply) ****

As part of our Nascentia Community Care team, the Nurse Practitioner Medical Provider (NPMP) has responsibility for providing continuous, coordinated, and comprehensive care of Nascentia members enrolled in our various health plans and community patients using a cost-effective, evidence-based approach. The NPMP independently performs comprehensive health assessments for a broad range of clients across care transitions, provides acute and chronic disease management, provides population health services including palliative and end-of-life care, orders and reviews medications, orders and interprets diagnostic tests, and participates in health screenings, home visits, and Health Risk Assessments.

The NPMP consults with physicians and specialists, leads and participates in multidisciplinary health care teams to develop, implement, and evaluate individualized treatment plans, and facilitates case management by evaluating the effectiveness of the plan of care (POC), making revisions as needed, and communicating regularly with allied health partners, patients and families to enable the POC.

The NPMP is expected to maintain compliance with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations ensuring that all diagnoses are ICD10, coded accurately, and documented appropriately to support the visit findings.

Performance Responsibilities and Standards:

Clinical Service Provision:

• • Demonstrates both autonomy and proficiency in performance of comprehensive historical, social, physical, and functional assessments.
  • Obtains and reviews medical history, conducts physical and psychosocial assessments, analyzes, and diagnoses conditions and develops appropriate plan of care.
• Pursues therapeutic interventions and diagnostic reasoning that reflect current cost-effective, evidence-based practice.
• Identifies prognosis / trajectory of chronic disease that may impact future health decisions and conduct advanced care planning discussions with the goal of improving care and reducing avoidable hospitalization.
• Collaborates with patient’s healthcare team to create a proactive Plan of Care focused on early prevention, detection, and timely intervention.
• Functions in a highly interactive mode, involving physicians/specialists, patients, family, staff, peers, support teams, and preferred providers, while focusing on preventive activities and/or best possible restorative care.
• Adheres to standards of documentation and communication, including those related to Plan of Care and encounter visit data.
• Complies with the practice parameters according to Nascentia, NYS DOH and CMS policies and standards.
• Develops an individualized comprehensive Plan of Care that aims to reduce the risk of adverse health outcomes.
• Identify risk factors and help mitigate barriers to access care and reduce risk.
• Communicates with healthcare team and family members during transitions of care.
• Documents patient encounters in EMR. Proficient in use of electronic medical records by company standards.

Case Management: Builds on the principles of primary care and Nascentia clinical guidelines to plan proactively for optimal outcomes. Effectively listens to and communicates with all members of the care team, incorporates the ideas of the team to consensus, and manages the agreed-upon plan with confidence and discipline.

Utilization Management: Facilitates a medically appropriate and effective POC to avoid polypharmacy, unnecessary duplication of testing, unnecessary ER utilization, prolonged hospitalization, iatrogenic illness, and fragmentation of care.

• Strategizes with physician and management team to enhance cost effectiveness of services while addressing continuing needs of patients, maximizing health potential, and supporting corporate mission.
• Coordinates with social services for appropriate community and supportive resources across all settings of care.
• Perform other duties as assigned, within scope of practice.

Leadership Activities: Assists managers and senior clinicians in the orientation of new team members. Serves as a resource to newer team members. Participates in committees and group projects as needed. Actively fosters open communication and a participative, team approach to agency planning and problem-solving.

Required Proficiencies:

• Clinical competence and understanding of evidenced-based practice. Extensive knowledge of the health and aging process.
• Utilizes critical thinking to determine appropriate treatment and least restrictive placement, acknowledging a patient's right of self-determination
• Demonstrates practical interpersonal communication skills.
• Brings an innovative approach to work, can "think outside the box."
• Takes a team approach in accomplishing treatment goals.
• Demonstrates sound judgment in anticipating problems or adverse outcomes; takes appropriate corrective action.
• Takes initiative to engage patients and other health professionals. Participates in activities that support continued competence as a nurse practitioner.
• Understanding Medicare, Medicaid, and Health Plan benefit structures is beneficial.
• Proficient in basic computer skills, such as sending e-mails, saving electronic files, retrieving saved documents, and searching the internet.

• Confidence in learning and using unfamiliar computer programs and electronic devices.
• Clear commitment to the care of the elderly and the attendant needs of their families
• Strong clinical, interpersonal and communication skills.
• Communicate effectively and demonstrate cultural competence with elderly and chronically ill patients and families.
• Superior organizational skills with the ability to multi - task and manage schedules.
• Excellent teaching skills
• Enthusiasm, flexibility, and pleasant demeanor
• Strong customer service orientation
• Previous experience working in home health or previous hospice, palliative care or wound care experience is desired.
• Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area.

License/Certification Requirements:

• Current active and unrestricted licensed as an Adult, Family or Gerontological Nurse Practitioner
• 2+ years of hands-on working experience as a Nurse Practitioner
• Experience working with complex patient populations including multiple chronic diseases with diverse psychosocial backgrounds.
• Possesses or is eligible for DEA licensure and CDS (if required).
• Basic Cardiac Life Support certification
• Willing and able to travel in the field as needed (mileage reimbursement available where applicable)

Physical Requirements:

• Speaking/visual/hearing ability sufficient to comprehend and express written/verbal communication.
• Frequent pushing, pulling, reaching, kneeling.
• Standing, sitting, bending, walking, and driving (frequently entering and exiting vehicle throughout the day) are standard postures.
• Frequently uses a laptop computer and mobile devices.
• Lifting requirements of up to 20 pounds frequently and up to 50 pounds occasionally
• Bloodborne Pathogens Exposure Category I - Employee has tasks that routinely involve exposure or potential exposure to blood, body fluids or tissues.

Compensation & Benefits

Competitive Salary [This position is an S08 exempt position with a min-max rate of: $111,018- $138,458/annually] with:

• $15,000 sign-on bonus
• Free Parking
• Continuous Mentoring
• 401K with generous Employer match
• On-Site Gym (free for all employees)
• Excellent work/life balance
• Medical, Dental, Vision Plans
• Partially funded HSA
• Employee Recognition Platform
• 3-6 month Training/Onboarding Program DOE
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!

About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

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Nascentia Health is an Equal Opportunity Employer (EOE)

Employment is contingent upon negative results of a pre-hire drug screen, and background check