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. Collaborate with the clinical care team and Medical Director to manage participant care plans and ensure comprehensive, individualized care.

Essential Duties and Responsibilities

• Provide high-quality primary care focusing on individualized evaluations, including comprehensive histories and physical exams.
• Collaborate with the IDT before referring participants to specialists, ensuring referrals are necessary and maintaining continuity of care.
• Manage and monitor participants' medications, aiming to exceed expectations in medication reconciliation and interactions.
• Stay informed of participant status during hospitalizations and facility stays, providing appropriate guidance for safe transitions and care continuity.
• Assume shared responsibility for all participants, supporting the IDT model of team-based care and participating in daily IDT meetings.
• Accurately document assessments and participant care plans, ensuring compliance with policy, regulatory, and quality standards.
• Review and respond to labs, imaging, and consults promptly, 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.
• Use the Emergency Department judiciously, prioritizing PACE resources unless symptoms are potentially life-threatening.
• Accurately document diagnoses with 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.
• Step into other roles as needed to support the team, maintaining clinical resource needs to the Medical Director.
• Consistently uphold all safety, privacy, and compliance standards.

Experience and Education

• MD, DO, APRN, NP, or PA
• Current State license
• CDS Certification and DEA Registration
• Board Certified in Geriatrics preferred
• BLS required (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
• If not present, training will be provided upon hiring (if applicable for the role).

Pre-Employment Requirements

• Reliable transportation, valid driver's license, and minimum state required liability auto insurance.
• Medical clearance for communicable diseases and up-to-date immunizations.
• Comprehensive criminal background check.

Benefits

Professional Growth: Access to training and career development.

Competitive Compensation: Medical/Dental Flex Time Off.

401K with Match.

Life Insurance.

Tuition Reimbursement.

Flexible Spending Account.

Employee Assistance Program.

Pay

Commensurate with experience.

Schedule

N/A