Sr Direct Care Practitioner - Boston, Bilingual preferred but not required

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health .

Job Summary

Under the direction of a Senior Products Manager, the Sr Direct Care Nurse Practitioner, as an advanced practice nurse (APN) in the Post-Acute and Long-Term Care Program, provides both primary and post-acute care and direct patient management to Senior Products members in designated facilities where we have established collaborative physician relationships. The SNF (skilled nursing facility) rounder will provide primary health care management to a long-term and custodial population with a focus on best practice approaches for the geriatric population as well as follow an identified subset of members who require post-acute management following an acute period of illness. The APN should be familiar with primary and preventative care approaches of the older adult with additional comfort in pharmacologic and end of life principles specific to this population. This oversight also includes annual wellness visits in facilities for eligible members.The APN will apply advanced practice skills to evaluate the older adult patient, provide medical management, and assess the patient’s progress toward identified goals to achieve the best possible clinical outcome along the health and illness continuum. This will be done in collaboration with all key stakeholders including collaborating physicians with whom the APN will build and support transparent and productive relationships.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• POST ACUTE CARE

• Performs comprehensive clinical exam and assessment upon admission

• Meets with facility staff and identifies the goal of the SNF stay

• Formulates discharge plan through discussion with multidisciplinary team with a focus on attainable goals and identified barriers

• Assess the patient at each visit to determine clinical status and progress towards goals

• Collaborates and communicates with members of the care team to establish expected length of stay, goals of stay and level of care.

• Serves as a resource for family, member, and case management teams to establish a mutually agreed upon discharge plan that is safe and attainable.

• Works collaboratively with all community case management teams and supports to optimize high risk discharge planning and care coordination

• Serves as a constant resource for the family and member

• Establishes collaborative relationships with supervising and collaborating physician groups and determines communication preferences between NP and receiving MD.

• LONG TERM CARE

• ANP will provide primary care to long term care population in designated facilities where applicable

• Expected to see monthly as well as when there is a change in status with a focus on treat in place conditions

• Serve as a resource of the families, members, and staff

• Experienced and skilled with end of life and goals of care discussions through care continuum as well as competent with Molst form completion and counseling

• CHA (COMPREHENSIVE HEALTH ASSESSMENTS)

• Performs annual comprehensive exams on all eligible members assigned in applicable facilities and geographies

• Knowledgeable with regards to risk adjustment coding and apply these concepts appropriately

• Facilitating clarification of patient and family goals of care and advanced directives

• Strong communication with all clinical teams including case management as it relates to issues identified during the assessment and recommendations that will overall benefit health and wellness trajectories

• Collaborate with all key stakeholders including primary care providers and case management teams with a goal to improve preventive care, eliminate crucial care gaps and improve the overall care experience

• Meeting attendance as required (monthly staff meetings, quarterly meetings with physicians)

• Licensure that is in good standing (APN, DEA, CSR)

• Actively participates in all quality and utilization management activities

• Functions as a licensed independent practitioner and able to work autonomously

• Adherences to all organizational training and compliance requirements

• Demonstrates initiative in achieving individual, team, and organizational goals and objectives.

• Accountable to performance metrics that are outcome, quality and productivity based

• Demonstrates the highest level of accountability for professional practice

• Proficiency with clinical systems and applicability

• Demonstrates cultural competency and sensitivity

• Practice and uphold all documentation standards in required and designated electronic systems

• Comply with all HIPAA regulations and maintain security of protected health information (PHI)

• Expected to participate in on call rounding rotation. This requires telephone availability evenings/nights to the facility RNs, to give verbal orders, and weekend rounding/new patient admissions as well as telephone availability.

• Other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Certified nurse practitioner through ANCC/AANP for adult, family, acute care, and/or geriatrics (GNP preferred)

• Current Massachusetts State license

• Current Drug Enforcement Administration (DEA) registration

• Current Massachusetts Department of Public Health (DPH) Controlled Substance Registration (CSR)

Education

• Required (minimum): Graduate degree from an accredited school of nursing and nurse practitioner program.

• Preferred:

Experience

• Required (minimum): 2 years of experience working with the frail or elderly population. Experience with computer systems, including web-based applications, electronic medical records, and some Microsoft Office applications (Word, Excel)

• Preferred: SNF experience; minimum two years of experience in primary care of the older adult as well as experience in nursing facility care preferred; Medicare and Medicaid experience preferred

Skill Requirements

• Strong communication and human relationship skills are required to work with a variety of medical, nursing, and allied health personnel as well as with patients and their families.

• Ability to exercise clinical and professional judgment and raise issues appropriately

• Strong attention to detail

• Experience with computer systems, including web-based applications, electronic medical records, and some Microsoft Office applications (Word, Excel)

• Works cooperatively as a team member across multiple levels within the organization

• Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgencies.

• Regard for confidential data and adherence to corporate compliance policy.

• Experience with motivational interviewing and/or health coaching a plus

• Comfort with end of life and goals of care discussions

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Work is performed at skilled nursing facilities and at times in t