Nurse Practitioner Medical Provider

*** THIS POSITION MAY BE ELIGIBLE FOR UP TO A $15,000 SIGN-ON BONUS (restrictions may apply) ****

As part of our Nascentia Community Care team, the Nurse Practitioner Medical Provider (NPMP) has responsibility for providing continuous, coordinated, and comprehensive care of Nascentia members enrolled in our various health plans and community patients using a cost-effective, evidence-based approach. The NPMP independently performs comprehensive health assessments for a broad range of clients across care transitions, provides acute and chronic disease management, provides population health services including palliative and end-of-life care, orders and reviews medications, orders and interprets diagnostic tests, and participates in health screenings, home visits, and Health Risk Assessments.

The NPMP consults with physicians and specialists, leads and participates in multidisciplinary health care teams to develop, implement, and evaluate individualized treatment plans, and facilitates case management by evaluating the effectiveness of the plan of care (POC), making revisions as needed, and communicating regularly with allied health partners, patients and families to enable the POC.

The NPMP is expected to maintain compliance with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations ensuring that all diagnoses are ICD10, coded accurately, and documented appropriately to support the visit findings.

Performance Responsibilities and Standards:

Clinical Service Provision:

• • Demonstrates both autonomy and proficiency in performance of comprehensive historical, social, physical, and functional assessments.
  • Obtains and reviews medical history, conducts physical and psychosocial assessments, analyzes, and diagnoses conditions and develops appropriate plan of care.
• Pursues therapeutic interventions and diagnostic reasoning that reflect current cost-effective, evidence-based practice.
• Identifies prognosis / trajectory of chronic disease that may impact future health decisions and conduct advanced care planning discussions with the goal of improving care and reducing avoidable hospitalization.
• Collaborates with patient’s healthcare team to create a proactive Plan of Care focused on early prevention, detection, and timely intervention.
• Functions in a highly interactive mode, involving physicians/specialists, patients, family, staff, peers, support teams, and preferred providers, while focusing on preventive activities and/or best possible restorative care.
• Adheres to standards of documentation and communication, including those related to Plan of Care and encounter visit data.
• Complies with the practice parameters according to Nascentia, NYS DOH and CMS policies and standards.
• Develops an individualized comprehensive Plan of Care that aims to reduce the risk of adverse health outcomes.
• Identify risk factors and help mitigate barriers to access care and reduce risk.
• Communicates with healthcare team and family members during transitions of care.
• Documents patient encounters in EMR. Proficient in use of electronic medical records by company standards.

Case Management: Builds on the principles of primary care and Nascentia clinical guidelines to plan proactively for optimal outcomes. Effectively listens to and communicates with all members of the care team, incorporates the ideas of the team to consensus, and manages the agreed-upon plan with confidence and discipline.

Utilization Management: Facilitates a medically appropriate and effective POC to avoid polypharmacy, unnecessary duplication of testing, unnecessary ER utilization, prolonged hospitalization, iatrogenic illness, and fragmentation of care.

• Strategizes with physician and management team to enhance cost effectiveness of services while addressing continuing needs of patients, maximizing health potential, and supporting corporate mission.
• Coordinates with social services for appropriate community and supportive resources across all settings of care.
• Perform other duties as assigned, within scope of practice.

Leadership Activities: Assists managers and senior clinicians in the orientation of new team members. Serves as a resource to newer team members. Participates in committees and group projects as needed. Actively fosters open communication and a participative, team approach to agency planning and problem-solving.

Required Proficiencies:

• Clinical competence and understanding of evidenced-based practice. Extensive knowledge of the health and aging process.
• Utilizes critical thinking to determine appropriate treatment and least restrictive placement, acknowledging a patie