Key Tasks & Responsibilities:

• Conduct comprehensive, acute, follow-up and transition of care encounters
• Collaborate with primary provider groups to address beneficiary medical management needs, including but not limited to:
  • Preventing avoidable hospitalizations
  • Developing and updating goals of care and advanced care plans
  • Supporting care transitions
  • Completing a medication reconciliation
  • Identifying beneficiaries appropriate for a palliative or hospice care pathways
  • Serve as a trusted advisor and advocate to beneficiaries, families, nursing home staff and provider partners
• Educates care teams on beneficiary needs and promotes early recognition of changes in condition
• Establishes and maintains meaningful relationships with patients, facilities and provider partners
• Performs other related duties as assigned to support high-quality, patient-centered care delivery

Supervisory Responsibilities:

• There are no supervisory responsibilities for this position

Credentials & Coverage:

• State unrestricted licensed Advanced Practice Nurse, National Board certification (AANP, ANCC or AACN) as an Adult, Family, Geriatric or Primary Care nurse practitioner required. Will allow acute care nurse practitioner with nursing home/geriatric or hospice palliative experience OR state unrestricted licensed Physician’s Assistant NCCPA board certified with nursing home/geriatric or hospice/palliative experience
• Active DEA license required
• Must have an active national provider number (NPI) and an active Medicare provider number
• Must be eligible to participate in the Medicare program as a provider and registered
• Valid state driver’s license with a good driving record and proof of automobile insurance required
• Auto insurance coverage as required by your state of residence. New employees will be responsible for providing proof of coverage prior to hire and on an ongoing basis

Education and Training:

• Master of Science in Nursing as a Nurse Practitioner from a nationally accredited program OR Master’s Degree from a nationally accredited program

Knowledge and Experience

• Minimum of 6 months experience as a Nurse Practitioner/Physician’s Assistant AND has some experience with geriatric/hospice or palliative care population prior to becoming an NP/PA OR is a licensed and board-certified new graduate NP/PA supervised by an experienced NP/PA in the Longevity Health New Graduate Fellowship program for 6 months and successfully completes all competencies for independent practice as a Longevity Health CareOne ACO APP
• Experience working in the nursing home environment is strongly desired
• Computer/Technology proficiency required
• The ability to engage and communicate effectively with physicians, patients, family members—excellent people skills
• Self-directed but functions well in a team environment
• Excellent clinical skills—assessment, diagnosis, treatment, prescribing specifically for the chronically ill population
• Can function independently, demonstrated critical thinking skills, organization, and prioritization skills