Senior Direct Care Practitioner, Bilingual Preferred

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Conducts thorough clinical examinations and assessments upon patient admission.

• Engages with facility staff to determine the objectives of the skilled nursing facility (SNF) stay.

• Develops a discharge plan in collaboration with a multidisciplinary team, focusing on achievable goals and recognizing barriers.

• Evaluates the patient during each visit to assess clinical status and monitor progress towards goals.

• Collaborates and communicates with care team members to define the anticipated length of stay, objectives, and level of care.

• Acts as a resource for families, members, and case management teams to create a safe and achievable discharge plan.

• Works in conjunction with community case management teams and supports to enhance discharge planning and care coordination for high-risk patients.

• Remains a constant resource for both families and members.

• Establishes cooperative relationships with supervising and collaborating physician groups, determining preferred communication methods between the Nurse Practitioner (NP) and the receiving physician.

• The Advanced Nurse Practitioner (ANP) will deliver primary care to the long-term care population in designated facilities where applicable.

• Expected to conduct monthly visits, as well as visits prompted by changes in patient status, with a focus on managing conditions in place.

• Serves as a resource for families, members, and staff.

• Experienced and adept in discussions about end-of-life care and goals throughout the care continuum, including completion and counseling related to the MOLST form.

• Conducts annual comprehensive examinations on all eligible members assigned in relevant facilities and regions.

• Familiar with risk adjustment coding and applies these concepts effectively.

• Maintains strong communication with all clinical teams, including case management, regarding issues identified during assessments and recommendations that enhance health and wellness outcomes.

• Collaborates with key stakeholders, including primary care providers and case management teams, aiming to enhance preventive care, eliminate essential care gaps, and improve the overall care experience.

• Accountable for performance metrics based on outcomes, quality, and productivity.

⛳️ Requirements

• Certified nurse practitioner through ANCC/AANP in adult, family, acute care, and/or geriatrics (GNP preferred).

• Valid Massachusetts State license.

• Current Drug Enforcement Administration (DEA) registration.

• Up-to-date Massachusetts Department of Public Health (DPH) Controlled Substance Registration (CSR).

• Graduate degree from an accredited nursing school and nurse practitioner program.

• Minimum of 2 years of experience working with frail or elderly populations.

• Proficient in using computer systems, including web-based applications, electronic medical records, and Microsoft Office applications (Word, Excel).

• Experience in skilled nursing facilities; at least two years in primary care for older adults, along with nursing facility care experience preferred; familiarity with Medicare and Medicaid is advantageous.

• Excellent communication and interpersonal skills are essential for interacting with a diverse range of medical, nursing, and allied health personnel, as well as patients and their families.

• Ability to exercise clinical and professional judgment and address issues appropriately.

• Strong attention to detail.

• Experience with motivational interviewing and/or health coaching is a plus.

• Ability to communicate clearly, and see and hear individuals effectively.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Retirement plans.

• Paid time off.

• Employer-paid life and disability insurance with additional buy-up coverage options.

• Tuition assistance program.

• Well-being benefits.

• Comprehensive benefits to support career development, individual and family health, and financial well-being.