Palliative Nurse Practitioner - Newark, NJ

Monogram Health is seeking a full-time Palliative Care Advanced Practice Provider (APP) to join the team to support our rapid nationwide growth. This Palliative Care APP will be an in‑market provider delivering in‑home care for a highly complex patient population in their community, including end‑of‑life patients with CKD/ESRD, diabetes, COPD, and CHF. The Palliative Care APP will support the Market Physician Executive, the Palliative Care Lead Physician, and an interdisciplinary team to provide palliative care, clinical guidance to patients and their families, including pain and symptom management, develop appropriate care plans and document advance directives to ensure patient‑centered care.

Palliative Care APPs are quality‑driven clinicians who apply their expertise in a managed care, population health context. They also engage in population health management in a sophisticated, outcomes‑driven manner that promotes palliative care where clinically appropriate and focuses on patient quality of life, education, and shared‑decision making.

They will collaborate with our interdisciplinary Pod teams and field clinicians to enhance care integration and optimize palliative care delivery to complex patients through Monogram Health’s comprehensive polychronic care model.

• Collaborate with the Market Physician Executive and clinical leaders including Palliative Care physician to proactively identify patients who qualify for palliative care services and build a patient panel
• Develop individualized care plans in collaboration with Market Physician Executive and other clinical leaders including Palliative Care physician to ensure patients are placed on appropriate evidence‑based interventions and pathways
• Provide compassionate, patient‑centric palliative care primarily through in‑home visits, with virtual care as needed, to support outcomes and care in alignment with patient’s goals
• Evaluate and treat symptoms that may interfere with quality of life, like pain, pruritus, depression, anxiety, insomnia, etc.
• Collaborate with pharmacists and other clinicians to manage medication panels for complex patients
• Provide resources and educate patients and their families on the progression of CKD, ESKD, and related conditions, including treatment options and palliative care principles
• Help families navigate complex medical decisions and improve understanding of prognosis, including advance care planning to discuss values, goals of care, and document patient/family wishes in state AD/POLST forms
• Deliver evidence‑based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first
• Support patients utilizing our interdisciplinary team, including Palliative Care Chaplain
• Assist with transition to hospice care as appropriate
• Participate in monthly meetings with clinical leadership to drive Program KPIs and support execution of clinical and financial goals
• Educate and support team members on palliative care, hospice care, advance directives, symptom assessment, and communication
• As needed for patient care, conducts assessments, which includes comprehensive annual wellness exams on patients both in the patients' home and in the virtual environment
• Counsels and educates patients and families about benefits and programs available to help them live healthier lives
• Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan. Completes all documentation and paperwork in a timely manner
• Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services
• This position will not be office‑based but will be remote in state in which employed and will need to attend periodic training/meetings outside of that state
• Prescribe medications, order tests, and collaborate with patient’s Monogram physician
• Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily
• Facilitates closing gaps in care by educating patients about…