Nurse Practitioner - Webster M-F

Overview

About us: Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation's top health plans for member experience, service, and clinical quality.

Fallon Health's Summit Elder Care is a Program of All-Inclusive Care for the Elderly-PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely  Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.

Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE- in the region.

Brief summary of purpose: Manages a primary care panel of participants and provides continuity primary health care to PACE participants that reside in the community or long-term care setting with a focus on goal oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant's goals of care. Works in close collaboration with all members of the PACE Interdisciplinary Team.

Establishes realistic goals and helps develop and manage individualized plans of care with the IDT team for program participants.

Provides primary health care to Summit Elder Care program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a participant-focused manner focusing on what matters most.

Works in close collaboration with the program's interdisciplinary team to establish realistic goals and care plans and develop and manage individualized plans of care for program participants.

• Performs post enrollment visits, biannual exams of participants and appropriately identifies and documents problems/issues in medical records
• Evaluates episodic illnesses and issues appropriate diagnostic and therapeutic orders
• Collaborates with physicians and other interdisciplinary team members to manage episodic and chronic medical needs of participants
• Addresses and documents Advance Directives/MOLST discussion for participants a minimum of annually and when a change in participant condition occurs
• Performs diagnostic, therapeutic and nursing intervention as indicated
• Provides continuity in monitoring of chronic, stable illnesses
• Implements the participant plan of care in a safe and effective manner
• Participates in interdisciplinary team meetings
• Evaluates effectiveness of previously implemented treatment
• Conducts home and nursing home visits as indicated
• Maintains accurate documentation and coding of all services provided according to professional standards
• Identifies utilization and service delivery problems and participates in identifying a resolution
• Identifies grievances and brings forward to leadership
• Participates in quality assessment activities including but not limited to record reviews, outcome measurement and review/revision of policies and procedures
• Provides education and training to participants, caregivers and staff in relevant topics
• Acts a resource to program staff and participates in defining care standards and practices
• Serves on appropriate committees, participates in all site and provider staff meetings including behavioral rounds and psychiatric rounds as indicated.
• Enhances personal professional growth and self-development through participation in professional activities including educational programs, current literature, in-service programs, trainings and workshops.
• Maintains BLS certification and professional certification as appropriate.
• May be asked to perform other duties that align with Fallon Health's…