NP will be assigned a panel of participants that are associated with Community Primary Care Physicians whose offices are located in a defined geography. The Community NP Lead will be responsible for forging a collaborative working relationship with each of these CPCPs and their respective staff to ensure that the practices are familiar with the PACE model of care and its special requirements and assure adherence to the individual plan of care and optimal outcomes This role will incorporate several critical functions including but not limited to:
- Serve as the lead of the CNPCS team, support the CMO with training to the new hires, and support the team providing guidance in coordination with the CMO or designated physician.
- Conducting in-person visits to the CPCP as needed to cultivate appropriate lines of communication around care coordination and care delivery for each participant. This will include providing a clear plan of communication and engagement including the delineation of the full range of clinical and social supports of serving frail elderly participants who reside in community settings.
- Defining protocols and expectations regarding the timely provision of required clinical documentation including in-office assessments specialist evaluations diagnostic reports including labs, imaging studies, and PCPC notes.
Experience & Skills Required
- Minimum of two years in clinical nursing practice in-home care, care management, or related field required.
- Effective oral and written communication and interpersonal skills required.
- High-level analytical and research skills.
- Ability to manage multiple projects and meet project deadlines.
- Basic Computer Skills in Microsoft office.