Nurse Practitioner - ElderONE

About the role

Join ElderONE, Rochester Regional Health's comprehensive PACE (Program of All-Inclusive Care for the Elderly) program, providing integrated, person-centered care to older adults with complex medical, functional, and social needs. This Nurse Practitioner role offers the opportunity to make a meaningful impact by helping participants remain safely in their homes and communities while collaborating within a highly engaged interdisciplinary care team.

Status: Full Time

Location: ElderONE, Department: Geriatrics

Schedule

Days; Monday-Friday, 8:00 AM-4:30 PM

Qualifications

• Passion for serving older adults and supporting nursing home eligible individuals to remain safely in the community
• Experience working with older adults and/or medically complex patient populations preferred
• Experience in PACE, Primary Care, Long-Term Care, Home Care, Geriatrics, or community-based care settings preferred
• Knowledge of care coordination, value-based care, and interdisciplinary team-based care preferred
• Strong problem-solving, organizational, and relationship-building skills
• Epic experience preferred; PACE experience a plus
• NP - Nurse Practitioner Certification - NYS Office of Professions
• RN - Registered Nurse - NYS Office of Professions

Responsibilities

• Clinical Care. Evaluate and manage acute, sub-acute, and chronic clinical needs of older adults. Collaborate with physicians and interdisciplinary team members to develop individualized treatment plans that align with participant goals, functional status, and quality of life.
• Care Management. Complete comprehensive clinical reviews of chronic conditions and document in the medical record. Assess and reassess participant-specific goals of care while reviewing specialty recommendations and coordinating appropriate follow-up care.
• Interdisciplinary Team Administrative Duties. Attend daily interdisciplinary team meetings and care planning conferences. Review laboratory results, specialty notes, and diagnostic testing, initiating orders when appropriate. Complete pre-enrollment visits and support care transitions and discharge planning activities.
• PACE & Community-Based Care. Support approximately 800+ ElderONE participants across multiple community-based sites and home settings. Partner closely with Primary Care, Home Care, Extended Care, and other system services to provide coordinated, person-centered care for a complex older adult population.
• Program Growth & Collaboration. Contribute to a growing and evolving PACE program through interdisciplinary collaboration, quality improvement efforts, process enhancements, and innovative approaches to care delivery.
• Infection Control. Utilize infection control equipment and safety guidelines to minimize and prevent exposure to communicable diseases, infectious body fluids, and risks associated with patient treatment.

Education

MS: Nursing (Required)

Requirements

Moderate - Clinical - Moderate clinical roles are patient facing roles that require continual movement, including standing