Job Description 

The Nurse Practitioner will act as part of a care team that directly interfaces with a small panel of patients with CKD stages 3b, 4, 5, and ESRD in order to drive high quality value-based care. He/she will interact with and evaluate patients in the home, via teleconference, or via telephone as appropriate. In this role, the NP will create close working relationships with the patients served and with the care team members. Every day will entail contact with care team members and patients to coordinate optimal care for the patient panel. 

Duties and Responsibilities 

• Assume medical responsibility for an assigned small panel of patients in collaboration with care team; provide clinical services focused on patient level interventions and system level interventions (both medical and kidney-focused). 

• Complete history and physical exams and order laboratory and diagnostic tests as needed. 

• Educate patients about medication usage and side effects, and prescribe medications as permitted by state prescribing authorities. 

• Identify and manage patients’ medical conditions and obstacles to care. 

• Participate in frequent care team huddles. 

• Educate patients and caregivers about medical conditions and treatment plans. 

• Order diagnostic and laboratory tests and evaluate test results. 

• Determine the need for consultation from medical, surgical, and/or psychiatric specialties. 

• Facilitate care across a variety of settings, including emergency department, hospital, skilled nursing facility, home health agency, hospice, and/or community-based organizations as appropriate. 

• Perform structured assessments and develop and implement comprehensive care plans for the patient panel. 

• Be available for after-hours telephonic support as needed. 

• Document all medical encounters accurately and in a timely manner. 

• Assist in the development and implementation of clinical protocols and guidelines of care in order to optimize outcomes. 

• Maintain confidentiality in regard to all patient sensitive information. 

• Support company efforts of continuous quality improvement. 

• Adhere to all company policies and procedures. 

Requirements

• Licensed Advanced Practice Nurse (APN) in the state of Florida. 

• Must meet Duo Health clinician credentialing criteria, including passing a background check and drug screen and meeting COVID-19 vaccine requirements. 

• Reliable transportation, Drivers License and a verifiable good driving record. Must be able to work from home, and able to travel to patient homes. 

• Must be self-motivated and able to perform work in accordance with defined operating procedures. 

• Ability to develop and maintain inclusive and equitable relationships with patients, caregivers and staff