Nurse Practitioner, Transitions of Care, 40 HHours (Days)

Position: Transitions of Care NP      

Department: Value Based Care

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Key Functions/Responsibilities:

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders

• Ability to execute core care management duties:

  • Comprehensive assessment: bio-psycho-social-spiritual

  • Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)

  • Implementation of care plan;

  • Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies, and skilled nursing facilities

  • Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.

• Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital

• Meet the patient where he/she is; observe the patient without intervention or judgment

• Has knowledge of common chronic medical conditions presented in the population served and is able to:

  • Educate the patient on their medication conditions and medications, and build their self-management skills;

  • Use motivational interviewing to promote behavioral change;

  • Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.

• Delegates assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion. 

• Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.

• Participates in local site operations, including team meetings, curbsides with care team members, etc.

• Actively participates in planning and growth of program with relevant stakeholders as needed

• Facilitates interdisciplinary consultation on patient’s behalf through participation in rounds, team meetings and clinical reviews

• Complies with established metrics for performance and adheres to documentation and work flow standards

• Maintains HIPAA standards and confidentiality of protected health information.

• Adheres to departmental/organizational policies and procedures.

JOB REQUIREMENTS

EDUCATION:

• Master's degree in nursing required. Completion of an accredited educational program for nurse practitioners required.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Current license to practice as a registered nurse in the Commonwealth of Massachusetts with authorization by the Board of Registration in Nursing to practice in an expanded role.

• Registered with the ANCC or other accrediting organization for Nurse Practitioners.

• Registered with the State of Massachusetts and DEA for prescription writing privileges.

• Current BLS and ACLS Certifications.

EXPERIENCE:

• Minimum of three years of current clinical nursing experience and two years experience in adult practice required.

• Prior experience in-related clinical practice preferred.

• Expert clinical judgment and ability to be self-directive and demonstrate initiative in an expanded role.

KNOWLEDGE AND SKILLS:

• Demonstrated critical thinking, problem solving and conflict resolution skills.

• Full command (verbal and written) of the English language.

• Demonstrated ability to apply principles of adult learning to provide effective patient and/or family education.

• Organizational skills to set priorities and efficiently complete assigned work.

• Effective interpersonal skills to facilitate communication with the various members of the health care team, patients and families.

• Computer proficiency inclusive of the ability to access, enter, and interpret computerized data/information required.

• Physical ability to meet the core job responsibilities in accordance with the practice setting demands for the patient populations regularly served.

This position requires working from home, community, and hospital.

Equal Opportunity Employer/Disabled/Veterans