Do you want to make a difference in healthcare?
Landmark Health was created to transform how healthcare is
delivered to the most medically vulnerable members in our
community. Our medical group provides home-based medical care
to chronically ill patients, many of whom are frail, elderly and
ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver
care primarily in the comfort of their home. Our Program is also
offered to eligible patients at no incremental financial cost
to them . We are not a fee-for-service practice; we benefit
economically only if we deliver high-quality patient outcomes and
satisfaction. As a result, our clinical teams can spend
quality-time caring for a smaller number of patients, giving all
patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now
the nation’s largest risk-based, in-home medical group.
At Landmark, our interdisciplinary teams collaboratively manage
our complex patient panels. These teams are led by Physicians,
Nurse Practitioners, and Physician Assistants, with supporting care
provided by RN Nurse Care Managers, Social Workers, Pharmacists,
Behavioral Health and other employed team members.
This position provides in home medical care and management to
home based Landmark members with documented or suspected behavioral
health conditions. Landmark recognizes that Behavioral Health
dramatically can impact Medical Health and this position
collaborates with the Chief Behavioral Health Officer, Associate
Director of Behavioral Health, Regional Medical Director,
PCP/Psychiatrist, interdisciplinary team and other health
professionals, to develop comprehensive member goals of care to
fully integrate medical and behavioral health care for optimal
outcomes and quality of life.
Focuses primarily on the Landmark population with identified or
suspected behavioral / mental health conditions and “adopts” these
patients to add psychiatric expertise to the medical management
plan and mitigate any negative impact that behavioral conditions
can have on patient overall health and well-being.
Actively participates with weekly Landmark interdisciplinary
team meetings to assure behavioral health issues are considered and
addressed for all high risk patients
Psychiatric NP establishes and maintains effective relationships
with members and their legal representatives, facility staff, PCPs,
existing psychiatrists and other collaborating mental health
providers to maximize continuity and compliance with individualized
member care plan.
Escalates and communicates any issues with Severely Mentally Ill
(SMI), complex mental health patients, and any active inpatient
psych admission with the Chief Behavioral Health Officer, Associate
Director of Behavioral Health lr local designee.
Practices in accordance with the respective state laws and
regulations governing the practice of advanced practice nursing or
Understands and complies with long-term care policies and
procedures, including those that regulate nursing facilities and
assisted living communities.
Performs an initial comprehensive assessment on all newly
enrolled members and at least annually thereafter. Develops a
member management care plan upon enrollment and updates it as
needed when changes in condition warrant or following
hospitalization. Meets with members and/or their legal
representatives to review newly developed or modified care plans;
involves the PCP in these meetings.
Calls and communicates directly with patient’s PCP in real time
to discuss any changes of condition and potential medication
changes. Plans will be collaboratively decided on with PCP, but if
unable to reach and emergent situation, NP will render appropriate
services and communicate changes at first available
Current, unrestricted State NP license
Completion of RN accredited program
Completion of accredited program in Psychiatric/Mental Health
Nurse Practitioner (PMHNP)
Minimum of two (2) years clinical experience, with home based
Knowledge of CPT, ICD-9 and HCPC codes
Knowledge of clinical standards of care.
Awareness about UM standards, NCQA requirements, CMS guidelines,
Milliman guidelines, and Medicaid/Medicare contracts and benefit
systems is helpful.
In order to work with potentially vulnerable patient populations
and to keep employees healthy while caring for patients, all
patient-facing employees of Landmark must provide evidence of the
following required immunizations/vaccinations as a condition of
employment: TB, MMR, Tdap, and Influenza. Declinations may be
accommodated based on your medical history, an allergy or religious
beliefs. Please immediately contact HR if you wish to apply for an
exemption from our vaccination requirements so that we may
determine if you qualify for an accommodation.