Nurse Practitioner Supervisor - Mobile Program

JOB PURPOSE:

The Nurse Practitioner Supervisor (NPS) - Mobile Program will work in collaboration with PACE Physicians, and community primary care physicians (CPCP) to ensure proper oversight and coordination of participant care with the Interdisciplinary Team. The NPS will support the participant’s functional, clinical, and psychosocial needs, with an emphasis on independence and wellness. This role will work as the liaison between the participant, the community physician, nursing homes, and plan staff to develop and implement the plan of care including person-center goal development, communicating changes in participant condition, and facilitating primary care preventative services.

The NPS
- Mobile Program will be assigned nursing homes, and PACE site where he/she will see all Center Light’s participants. Supervises and manages Nurse Practitioners assigned to their location and assists with the oversight of other Diagnostic Treatment Center’s clinical staff as needed. Complete direct reports annual performance appraisals and collaborate with other DTC Managers providing annual performance feedback of the DTC clinical staff as needed.

In the absence of, or at the direction of, the Medical Director, the NPS will represent or serve as the Medical Director role at their location. At a minimum, performing annual wellness assessments on all assigned site participants, and ensure reflects an understanding of the complexity and multiple comorbidities of the frail and/or elderly. For participants with higher levels of risk, these assessments will be performed more frequently to appropriately address his/her level of need as described below.

Provides urgent care services to participants and facilitates the provision of same day access. Assesses and manages participants with acute changes in condition in a timely manner. Assesses participants upon return from the hospital/Emergency Department within 5 days. This includes the reconciliation of medications and treatment plans and coordination with the participant’s CPPCP and IDT members to ensure the timely transition of care follow-up visits.

Reviews patient’s past medical history at least every 6 months and formulates a comprehensive and complete diagnostic list of current and past medical conditions using clinical knowledge and judgment and the findings of his/her assessment. The NPS is responsible for ensuring that all such documentation is complete and accurate, and specific diagnosis codes will be documented in CL’s clinical platform and as encounter data as required.

Participates in all clinical documentation improvement activities with the goal being an accurate and full capture of the burden of illness of our participants and appropriate risk adjustment. Provide feedback and counseling to DTC and IDT staff regarding their clinical documentation as needed. Reviews the Participant’s current symptoms, and exacerbation of problems that were previously controlled and identifies active diagnoses and chronic problems or conditions to be used in Care Management and active medical management of treatment and designed interventions.

Co-manages the highest risk subset of participants with the PCPs and communicates findings of assessments to inform Participant’s PCP of potential gaps in care and coordinates with CPCP on a care plan that will address these gaps. Attends and participates in CL’s Interdisciplinary team (IDT) meetings and represents CPCP when he/she is unavailable to attend or delegates the role to the NP.

Communicates with CL’s IDT team or other CL Plan designees in accordance with CL’s policies and procedures. Participates in complex care management and educates participants and their families and CL staff on…