Field Based Family Nurse Practitioner - Evernorth - Philadelphia PA

We are a premier home-based healthcare solution for patients and families facing chronic, complex and life-threatening illness.  We are an innovative, multi-specialty practice experiencing tremendous growth nationwide. We offer patients and families a complete population health model, focusing our practice in caring for patients across the continuum of complex and serious illness.

Our focus is comprehensive care at home to improve quality of life, increase understanding and management of serious illness, facilitate coordination between providers, and decrease unnecessary healthcare cost.   We are an interdisciplinary group of clinical professionals that understand the needs of patients, medical professionals, health systems and payers.  We meet the patients where they are within the continuum of serious and complex illness; we provide the right level of care at the right point in time.  This includes health risk assessments, transitions of care, complex and chronic disease management, and palliative care support. We conduct in-home longitudinal care for medically complex patients with chronic illnesses in an effort improve clinical outcomes and decrease utilization.  We provide physical, emotional, and spiritual support for patients who are facing life-threatening illnesses.

We are currently seeking nurse practitioners who are passionate about serious illness care and management to join our growing house calls practice to provide both chronic disease management and palliative care support, as we further extend our operations serving a variety of Medicare Advantage, Medicaid, and Commercial clients.

Duties & Responsibilities:

• Perform home visits with patients enrolled in chronic care risk program. Initial visits are comprehensive evaluations with subsequent visits targeting risk factors for disease exacerbations and hospitalizations.

• Working closely with other team members to ensure quality care is delivered.

• Coordinate with patient's other providers including PCP, specialists and health plan case managers to ensure all are working together with the patient to achieve the same health goals

• Sharing after hour on-call coverage with other providers on the team.

• Working with field and office RN and medical assistants.

• Clinical documentation of acute and chronic healthcare issues  through patient encounter in EMR system

• Documentation must be appropriate and thorough, and completed in a timely manner

• Provider will ensure all appropriate consent forms are signed and dated

• Provider will have frequent interaction with patients, coders, schedulers, and supervising physician

• The provider will educate patients and/or patient’s family on chronic medical conditions, preventative care, and medication adherence compliance

• Provider will participate in weekly telephonic clinical meetings and occasional web-based compliance trainings;  however, provider will occasionally be required to attend on-site training

• Provider will prescribe medications, order labs or diagnostic testing, and make sub-subspecialty referrals collaborating with the community PCP.

• Provider will be responsible to review  patient records for past and present health issues, being sure to update the chart accordingly

• Provider will need to collaborate with the supervising physician and other members of health care team to ensure outstanding patient care is delivered

• Provider must be able to interpret laboratory data and diagnostic testing when available to assist in diagnosis of medical conditions

• As part of the initial, and subsequently annual, assessments the provider must screen for ADL/IADL deficits, fall risk, depression, cognitive impairment and nutritional health.

• Medication reconciliation done at every visit.

• Performs other duties as assigned by the supervising physician and/or manager

Knowledge, Skills, Abilities and Requirements:

• Graduated from an Advanced Nurse Practitioner program in Adult, Geriatric, or Family Nurse Practitioner.

• Active, unrestricted NP license in respective state

• NP candidates must be board certified by the ANCC or AANP or geriatrics, and have current RN and NP licensure in state of practice

• Must have current BLS certification; ACLS preferred. 

• Must be able to be credentialed by Medicare, Medicaid, and other Private Insurance Companies

• DEA license and State Controlled Substance License upon hire or within 6 months of hire;

• Experience with electronic medical records is required.  Also required is proficiency with various computer-based applications such as Microso