PCP Nurse Practitioner

Job Summary

Deliver primary care and continuous healthcare services to PACE participants, assessing, planning, and providing care in alignment with PACE Program standards. Work closely with the clinical care team to conduct assessments, reassessments, develop care plans, and deliver comprehensive primary care.

Essential Duties and Responsibilities

• Provide high-quality primary care with a strong focus on individualized evaluation, starting with a comprehensive history and physical exam, rather than defaulting to broad diagnostic testing panels.
• Collaborate closely with the IDT before referring participants to specialists, ensuring referrals are necessary and maintaining continuity of care.
• Collaborate with the Medical Director to manage specialist referrals, initiate appropriate treatment prior to referral when indicated, review specialist notes promptly, and develop and communicate participant care plans that incorporate clinical judgment and consult findings to ensure comprehensive care.
• Manage and monitor all of your participants' medications, aiming to exceed expectations in medication reconciliation, and medication interactions.
• Stay actively informed of participant status during hospitalizations and facility stays, providing appropriate guidance to ensure safe transitions and care continuity.
• Absorb shared responsibility for all participants in the center, supporting the IDT model of team-based care.
• Participate in and contribute to daily IDT meetings, offering clinical insights and collaborating on participant-centered care plans.
• Ensure accurate, timely completion of all participant assessments and documentation in compliance with policy, regulatory, and quality standards.
• Review and respond to labs, imaging, and consults in a timely manner, incorporating findings into ongoing care plans and communicating changes with the IDT.
• Educate participants and caregivers on self-care strategies, medication use, and wellness practices, empowering them to participate in their own care.
• Use the Emergency Department judiciously, prioritizing PACE resources unless symptoms are potentially life-threatening.
• Accurately document diagnoses with attention to proper coding practices, supporting risk adjustment and quality reporting metrics.
• Provide coverage for the 24/7 on-call rotation, addressing participant needs promptly and ensuring proper hand-offs and communication.
• Contribute to discharge planning, supporting smooth transitions across care settings.
• Assist with staff training and mentoring, contributing to clinical policy development and best practice implementation.
• Participate in ongoing performance and quality improvement initiatives.
• Demonstrate flexibility by stepping into other roles, as allowed by licensure and experience, when needed to support the team.
• Maintain and report clinical resource needs to the Medical Director, supporting effective operations.
• Consistently uphold all safety, privacy, and compliance standards.

Experience and Education

• MD, DO, NP, APRN, or PA
• New Jersey: Each nurse practitioner shall be so certified by the New Jersey State Board of Nursing. Each physician shall be licensed or authorized by the New Jersey State Board of Medical Examiners to practice medicine in the State of New Jersey.
• State CDS Certification and DEA Registration
• Board Certified in Geriatrics preferred
• BLS required (must have within 90 days of employment)
• 2 years experience providing direct patient care (preferred)
• 1 year of experience working with a frail or elderly population preferred

Pre-Employment Requirements

• Reliable transportation, valid driver's license, and minimum state required liability auto insurance.
• Medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
• Comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.

Benefits

• People First Environment
• Make an Impact
• Professional Growth
• Competitive Compensation
• Medical/Dental Flex Time Off
• 401K with Match
• Life Insurance
• Tuition Reimbursement
• Flexible Spending Account
• Employee Assistance Program