Primary Care Nurse Practitioner (NP) - Trenton, NJ

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 a Primary Care Nurse Practitioner, you will:

• Be accountable for the care and outcomes of a cohort of patients to be managed directly, and in close collaboration with the Physician Team Lead.
• Meet key metrics as determined by the practice, such as ensuring our patients are enabled to stay at home whenever possible. 
• Visit patients primarily in their homes, as well as through telehealth when appropriate.
• 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 risk and interventions to mitigate these.
• Achieve high performance on CMS and NCQA-determined STARS and HEDIS quality metrics, respectively.
• Provide care that is consistent with medical evidence, 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.

You will love this job if:

• You are passionate about caring for our most vulnerable elders, including those with multiple chronic conditions, frailty, and advanced illness in the home setting.
• You enjoy team-based collaborative care across multiple disciplines and specialities.
• You love developing relationships with your patients and their caregivers.
• You embrace technology and clinical protocols as a means for driving high quality clinical care.
• You are flexible and comfortable working in an evolving environment that values continuous improvement.
• You embrace measurement and performance management to drive improved patient outcomes.

You should get in touch if:

• You are based near Trenton, New Jersey and can travel to Somerset, Middlesex, and Mercer county (required).
• You have a BSN from an accredited program AND a master's degree in advanced clinical practice nursing or a post Master’s certificate (required).
• You have an active license to practice in the state of New Jersey (required).
• You have an active DEA and CDS registration (required).
• You have a minimum of 3 years experience in Primary/Family Care, Internal Medicine, Geriatrics, or Hospice/Palliative Care (required).
• You have worked in a housecalls setting previously, fee-for-service and/or value based (preferred).
• You enjoy working with patients of diverse social, ethnic, and cultural backgrounds.

Benefits Overview:

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based b