Job Summary
Apply clinical skills to the management of healthcare for medically complex older adults, working collaboratively with an interdisciplinary team to address participants' medical, emotional, and social well‑being.
Responsibilities
- Work as a member of the PACE Interdisciplinary Team (IDT) responsible for:
- Preparing and updating a comprehensive Care Plan in conjunction with the IDT that includes medical, emotional, and psychosocial aspects of care.
- Responding to input from team members, participants, and caregivers, and communicating important clinical information to the IDT.
- Perform functions including but not limited to:
- Conducting comprehensive history and physical exams for new participants to assist with Care Plan preparation.
- Reassessing participants' medical conditions at least every six months as part of the semi‑annual assessment.
- Managing participants' medical care for acute and chronic issues.
- Reviewing outside clinical information for participants, such as specialty clinic appointments, hospitalizations, and nursing home stays.
- Documenting changes in a participant's condition in the medical record in a timely manner, consistent with documentation policies established by the medical director.
- Working in the PACE clinic at either of the two PACE centers to see participants as scheduled and as needed.
- Providing in‑home care as required.
- Contacting and informing caregivers of any medical changes.
- Returning calls from participants, caregivers, and staff in a courteous and timely manner.
- Serving as the provider on‑call for on‑call nurses during evenings and weekends, and returning calls in a courteous and timely manner.
Competencies
- Effective communication with patients, caregivers, healthcare professionals, and non‑medical colleagues, ensuring understanding.
- Fostering caring interpersonal connections with participants and their caregivers.
- Enthusiastic collaboration with colleagues in a team environment.
- Navigate complex ethical issues involving participants sensitively.
- Proactively seek ways to improve delivery of care.
- Serve as a trusted liaison with the medical director, nurses, and other healthcare professionals within the program.
- Support other team members with their roles and responsibilities.
- Appreciate and learn from the knowledge of others on the team, sharing knowledge in return.
- Participate in research or investigations related to quality improvement.
- Creatively propose and adapt treatment plans with openness to unique circumstances of PACE participants, focusing on delivering goal‑concordant care.
Physical Requirements
- Prolonged periods of sitting at a desk and working on a computer; must be able to lift fifteen pounds at times.
- Stand less than 33% of time on duty.
- Walk less than 33% of the time on duty.
- Sit between 33% and 66% of time on duty.
- Use hands to finger, handle, or feel over 66% of time on duty.
- Reach with hands or arms less than 33% of time.
- Full ability to talk and hear.
- Correctable vision required.
- Able to lift or carry up to 30 lbs.
Minimum Educational And General Qualifications
• Nursing degree from an accredited university and graduate of a certified or accredited Nurse Practitioner Program; or Master’s degree in Clinical Nursing and five years nursing experience. Must hold a current license as an Advanced Practice Registered Nurse (APRN).
• Preferred: Five to seven years of nursing experience, with three years of experience as a Nurse Practitioner.
Salary
$56.00 – $63.00 per hour