Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.
JOB SUMMARY:
The nurse practitioner treats acute and chronic conditions in place while maintaining the highest level of daily function possible for CPDL members. Scope of responsibilities include building connections with members, designated representative and the interdisciplinary care team (ICT) through assessing needs, creating individualized care plans, coordination of care to ensure smooth transitions across settings.
PRIMARY RESPONSIBILITIES:

• Provide proactive primary and acute care to members
• Manage members with acute change in condition in collaboration with primary care physician and the ICT
• Reviews and manages pharmacotherapy of each member, collaborating with clinical pharmacist and physicians when necessary.
• Prescribe appropriate medications, including controlled substances in accordance with NYS law
• Identify, treat, and document changes in condition
• Order, review and/or follow-up with treatments and diagnostic testing
• Daily review nursing home reports, logs, medical records, etc
• Complete timely health risk assessments
• Complete routine monthly comprehensive assessments
• Ensures appropriate and timely utilization of services requests, such as consultation with specialists.
• Ensures a smooth transition and assists in the coordination of care across various health care settings
• Attends nursing home meetings, participate in ICT meetings involving CPHL members
• Communicate with the nursing home staff on a regular and as needed to discuss changes in condition and/or the care plan
• Communicate with ICT
• Communicate with the family or designated representative regularly about significant changes in condition and/or therapies
• Discuss and educate member and designated representative on ACP.
• Act as point of contact for member, family or designated representative, throughout transition process, change in condition, routine updates
• Works with the ICT to optimize the health and functional status of the members. Also works to enhance pain management strategies, thereby improving the quality of life of the members.
• Provide clinical education and support to nursing staff as needed
• Provide ongoing education and support to member and family or designated representative regarding the member’s health status, established goals
• Participate in pre-planned marketing events with nursing home residents and families
• Active role in training nursing home staff to CPHL MOC
• Participate in an ‘on call’ program, providing telephonic and/or on site assessments and interventions for the members after hours and on weekends.
• Management of the skilled day process
• Comply with nursing home and CPHL policies and procedures
• Follow both nursing home and CPHL reporting procedures for incidents, appeals, grievances

EDUCATION AND EXPERIENCE:
Education
Required: Master’s level degree in nursing with completion of an accredited NP (adult or geriatric)
Preferred:
Type of Experience
Required: Minimum of one (1) year recent clinical experience with elderly population. Previous experience in I-SNP, HMO
Preferred:
Specific Technical Skills
Certifications/Licensure:
Required: Advanced practice nurse prescriber licenses and DEA registration
Knowledge and Skills:

• Strong communication skills.
• Building relationships
• Working knowledge of clinical documentation requirements & Medicare Risk Adjustment coding

Preferred:
SCOPE INFORMATION
# Direct Reports:
PHYSICAL REQUIREMENTS:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required.
Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.