Part Time Community Based Nurse Practitioner Greenbelt

Duties And Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges.
• Manage a small panel of homebound members who require primary care.
• Resolve acute issues in the home and clinic or by directing member to most effective and efficient solutions.
• Evaluate acute exacerbations of chronic conditions.
• Handle acute onset of illnesses, shortness of breath without chest pain, change in mental status, and new onset hypoxia.
• Assess and treat various infections, new or worsening aches and pains, wounds, depression, and anxiety.
• Ensure timely and accurate completion of chart documents.
• Work with the Core Clinical Team (PCP, Care Manager or SW) to define visit goals.
• Communicate important post-visit follow-up information to the Core Clinical Team.
• Collaborate with the Integrated Care Team (ICT) members (behavioral health, nutrition, health education) for problem-solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs, such as abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
• Implement transitional care protocols as part of warm hand-offs between internal and external care providers.
• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
• Adjust care plans following guidelines for evidenced-based chronic disease management.
• Educate and coach for medication adherence and chronic disease self-management skill development.
• Maintain monitoring of members at risk of being lost to care and implement interventions to prevent loss.

Education & Experience Requirements

• This is a Community Based position must be willing to do home visits.
• Certified Registered Advanced Practice Provider in a field of Adult Medicine with Acute Care experience.
• ACLS certified.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
• Ability to meet deadlines and manage multiple priorities.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.
• Familiarity with care transitions, strategies for reducing readmissions, and chronic condition management interventions.

Preferred Qualifications

• Experience in a Patient Centered Medical Home.
• Experience working with high-risk and medically complex patients with multiple comorbidities.