Nurse Practitioner - Transitions Medical Partners - Primary Care

Responsibilities

• Provide comprehensive primary care services, including health maintenance, preventive care, and management of acute and chronic medical conditions.
• Perform patient assessments, physical examinations, and diagnostic evaluations.
• Diagnose and manage common primary care conditions (e.g., hypertension, diabetes, COPD, CHF, dementia, depression, and other chronic illnesses).
• Order, review, and interpret diagnostic tests and laboratory studies.
• Prescribe medications and therapeutic interventions consistent with scope of practice, collaborative agreements, and regulatory requirements.
• Provide patient and caregiver education focused on disease management, health promotion, and self-care.
• Participate in on-call rotation schedule with MD / Medical Director and team.
• Provide palliative care consultation and hospice visits in residential facilities, home settings, hospice inpatient facilities, and hospitals.
• Deliver pain and symptom management interventions based on established hospice and palliative care guidelines and standards.
• Conduct goals-of-care discussions, advance care planning, and shared decision-making with patients and families.
• Attend Interdisciplinary Group (IDG) meetings as appropriate.
• Carefully coordinate transitions of care across inpatient, outpatient, home-based, and residential settings.
• Communicate effectively with referring providers, facility staff, and community partners to ensure continuity and quality of care.
• Document accurately and timely in the patient medical record in accordance with federal, state, regulatory, and agency requirements.
• Aid with data collection, quality metrics, forms, and outcome evaluation tools for primary care, palliative care, and hospice programs.
• Collaborate with the Chief Medical Officer and Associate Medical Director to educate hospital staff, residential facility staff, and community physicians on:
• Primary care integration
• Chronic disease management
• Palliative care principles
• Pain and symptom management
• End-of-life communication
• Available Transitions LifeCare programs
• Perform other duties as assigned by supervisor.

Requirements

• Nurse Practitioner with current North Carolina license.
• Minimum 3 years of clinical experience preferred.
• Experience in primary care, internal medicine, geriatrics, hospice, palliative care, and/or home health preferred.
• ACHPN certification preferred.
• Maintain continuing education requirements for Nurse Practitioner licensure.
• Knowledge of reimbursement sources, Medicare regulations, licensing laws, and accreditation standards.
• Computer proficiency preferred.
• Current CPR certification.
• Valid North Carolina Driver’s License, active automobile insurance, and access to reliable transportation.

Expectations

• Demonstrate professionalism, compassion, respect, teamwork, and accountability in all interactions.
• Adhere to all Transitions LifeCare policies, procedures, and organizational guidelines.
• Deliver care in accordance with ACHC Standards and Medicare Conditions of Participation as applicable.
• Comply with all state and federal laws, regulations, and professional standards within defined scope of practice.
• Communicate concerns, risks, or quality/safety issues promptly to leadership.

Environmental Factors

• Potential exposure to bloodborne pathogens.
• Opportunity for exposure to communicable diseases or bodily fluids.