NP

Company: Taflink Group
Location: Worcester
Posted on: September 13, 2020

Job Description:

As a Nurse Practitioner, you will work in a radically different model of healthcare for our client --- Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners --- Co-manage a panel of members to improve their health holistically through longitudinal primary care, care management, and care coordination and be available via phone, during business at our hubs, or for member home-visiting Provide comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care. Perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization --- Conduct several home visits in a given day, including scheduled and unscheduled urgent member needs Perform post-discharge visits for your panel within 48 hours of discharge from either an acute care facility or skilled nursing facility to decrease the risk of readmission; perform detailed medication reconciliation, and assure that appropriate long term services are in place --- Assess cases presented to you by your Care team and utilizing your clinical competencies, prioritize member needs --- Interface with specialists, hospitals, and community-based organizations to facilitate collaboration in service of our members, and promote shared decision making --- Monitor and address clinical quality gaps in care --- Utilize our custom-built care facilitation platform, Commons, and the market's EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources --- Assist management and leadership with the development, refinement, and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects --- Attend daily team huddles and weekly case conferences to advise on physical health needs and establish health goals as part of member's Member Action Plan (MAP) Requirements for the Role: --- You are a Board-Certified (or Board-Eligible within one year of employment) Nurse Practitioner or Physician's Assistant with an unrestricted license to practice in the state in which you are seeking employment with Cityblock (MA) --- AANC or AANP certification for Nurse Practitioners --- Active DEA Controlled Substance Registration or eligible for application --- Certified in Basic Life Support for Healthcare Providers --- Maintenance of professional credentialing and CME standards Job Requirements Required Skills and Experience: - You are a Board-Certified (or Board-Eligible within one year of employment), Nurse Practitioner or Physician's Assistant with an unrestricted license to practice in MA - NP is preferred. - 3+ years of experience as an NP, or 10-15 years as a Physician's Assistant - AANC or AANP certification for Nurse Practitioners - Active DEA Controlled Substance Registration or eligible for application - Certified in Basic Life Support for Healthcare Providers - Maintenance of professional credentialing and CME standards - You have experience providing clinical services to individuals with both chronic medical and behavioral health conditions and have an interest in serving complex, vulnerable, and disabled populations * You have an unrestricted driver's license and vehicle for daily use You have an unrestricted driver's license and vehicle for daily use --- Work a full-time 40 hour week, Monday-Friday 9 am to 5 pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits. --- You have experience providing clinical services to individuals with both chronic medical and behavioral health conditions and have an interest in serving complex, vulnerable, and disabled populations --- Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy), assessment, and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression. --- Proven skills, knowledge base, and judgment necessary for independent clinical decision-making --- You are an adaptable organized, efficient, independent self-starter and problem- solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of the whole community health --- You are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care --- You will also participate in a regular Saturday Rotation and on-call schedule. Your work may take you outside of normal business hours as urgent member needs arise How We Define Success: --- Manage a complex population of members in collaboration with an interdisciplinary team --- Ensure members on your panel receive appropriate care for acute and chronic diseases, including the following ED visits and acute admissions --- Decrease unnecessary hospitalizations, emergency room visits, and unnecessary specialty referrals --- Complete comprehensive provider visits. Identify core member needs the team will address to improve health outcomes and decrease the total cost of care --- Meet evolving monthly and quarterly targets, in both clinic and home setting --- Engage in target setting for new clinical initiatives and managing those targets Nice to Have, But Not Required: You have experience caring for members in a low-income community or in a community health setting You have experience with Geriatrics, Family Medicine, or Palliative care You have experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff Multilingual Employment Type: Full Time Years Experience: 3 - 5 years Salary: 128000.00 Annual Bonus/Commission: No

Keywords: Taflink Group, Worcester , NP, Other , Worcester, Massachusetts