Palliative Care Nurse Practitioner (NP) - North Jersey

MEET CLOVER HEALTH HOME CARE

Clover is reinventing health insurance by working to keep people healthier.

Our mission is to improve every life by providing compassionate, reliable and equitable care to those who need it most. Our care model takes a team based approach that is aligned with the personalized needs, values and preferences of our patients, families and caregivers. Our Supportive Care interdisciplinary team includes physicians, nurse practitioners, nurses, social workers, medical assistants, behavioral health specialists and others who collaborate and coordinate to provide home based care.

As an Palliative Care Nurse Practitioner (NP), you will:

• Be accountable for the care and outcomes of a cohort of supportive care patients to be managed directly, and in close collaboration with the Palliative Care Physician.
• Achieve meaningful outcomes by meeting key practice metrics, including empowering our patients to safely remain at home whenever possible and ensuring seamless, timely transitions to hospice care when needed..
• Visit patients in their homes, as well as through telehealth in a hybrid role.
• Actively participate in Interdisciplinary Team (IDT) Meetings with an attitude of curiosity, and a willingness to teach and to learn.
• Contribute medical expertise during IDT to structure care plans that reflect:
  • Patients' prognoses and disease trajectory, inclusive of goals of care and advanced care planning.
  • Primary drivers of hospitalization/ED visits and develop effective interventions to reduce these risks.
• Contribute to the practice achieving high performance on CMS and NCQA-determined STARS and HEDIS quality metrics, respectively.
• Provide care that is consistent with medical evidence guidelines, including identified clinical protocols.
• Proactively involve other providers on the patients’ care team, including PCPs, specialists, home health, hospice and home care organizations.
• Determine the need for consultation from medical, surgical, rehabilitative, and/or psychiatric specialties, which may include deprescribing and simplification where clinically appropriate.
• Determine the need for and facilitate care by an emergency department, hospital, skilled nursing facility, home health agency, hospice and/or community-based organization as appropriate and consistent with patients’ goals of care.
• Provide medical administrative support, such as signing forms that may require signature.
• Complete documentation of all clinical encounters in a timely and accurate manner in accordance with practice standards, including proprietary Clover tools such as Clover Assistant.
• Collaborate with the practice Medical Director and Practice Manager in efforts of:
  • Continuous quality and process improvement, including those related to the EHR and Clover Assistant.
  • Ongoing evolution of the care delivery and operational models.
• Participate in the on call rotation as set by the Medical Director.
• Establish a positive image for the practice in the medical community.
• Behave in a way that espouses Clover values.
• Take on projects and initiatives requested by the Physician Team Lead, Medical Director and/or the leadership team.

Success in this role looks like:

In the first 90 days, you will understand our systems and processes and begin to build rapport with patients, families and the team. Success includes:

• Learning our technology and platforms to effectively and efficiently deliver care for your panel of patients.
• Establishing relationships with the interdisciplinary team and understanding the role of each team member.
• Demonstrating effective communication and collaboration skills with patients, families, and the care team, especially in care planning and patient discussions.

In the first 6 months, you should be fully integrated into the clinical environment and have developed a deeper understanding of your patient population. Success looks like:

• Demonstrating the ability to effectively identify, enroll and transition eligible patients to hospice. 
• Contributing valuable insight during IDT rounds, particularly around symptom management, prognostication, communication skills, and complex end of life decisions. 

In the future, you will be delivering consistent, high-quality care, and contribute to the growth of the palliative care program.  Success looks like:

• Being recognized as an expert in palliative care, being trusted by colleagues and patients for clinical decision making and symptom management.
• Strong, consisten