Nurse Practitioner for Care Management

Job DescriptionESSENTIAL JOB FUNCTIONS: * Care Management (70%) * In collaboration with PCPs, manage a panel of patients who have been identified as needing care management due to uncontrolled medical or mental health condition, or social determinants of health and have agreed to participate in care management. . * Work directly with patients with complex or chronic health problems. Coordinate with PCP and care team to create and carry out individualized, patient-centered care plans for the most complex patients. * Provide education and coaching to patients around wellness, nutrition, lifestyle changes, medication management and disease management. * Assist patients in navigating the Health Care System, connecting with local agencies and accessing resources in the area. * Assist with providing safe transition of care across the continuum of care, including patient visits after emergency visits and hospitalizations. * Implement monitoring systems for high-risk patients to prevent and/or intervene early during acute exacerbations. Manage acute exacerbations of chronic conditions using evidence-based medicine. * Evaluate laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for assigned population. * Collaborate with community agencies to ensure a smooth process is in place when patient movement between settings occurs. * Facilitate discussions with PCP and other members of the care team regarding patient care and concerns. * Participate in CCPM care management meetings and other care management meetings as requested. * Develop care plans which include a problem list, expected outcomes/prognoses, treatment goals, medication management. * Develop a schedule with each patient where their care plan is reviewed and revised. Walk-in /Acute Direct Patient Care (30%) * Provide diagnoses, treatment and/or proper referrals while maintaining expected medical standards. * Evaluate patients in a timely and courteous manner. * Maintain confidentiality of patient care and health center operations at all times. * Function as an advocate for patients, particularly those with fewer economic and social resources. Quality Improvement/Quality Assurance : Nurse Practitioners are expected to participate in and provide leadership for quality improvement and assurance activities throughout the organization. * Appropriately document medical care in electronic medical record and close medical visits within 72 hours. * Follow primary care practice guidelines, including preventative services, immunizations and chronic disease management. * Participate in quality improvement programs that will assure that patients receive quality care in the office and from other providers of health care services using peer review, audits of medical records, grievances, and other mechanisms as appropriate. * Follow protocols for Incident Reporting, Emergency Preparedness, and organizational safety in order to promote patient and staff safety. * Follow appropriate infection control procedures and use personal protective equipment as appropriate. * Remain current on all required annual trainings. Continuing Education : Nurse Practitioners are expected to be lifelong learners, always looking to learn new things that improve patient care. * Participate in or conduct in-service training for the providers of Greater Portland Health (GPH). * Attend continuing medical education (CME) programs and provide copies of course completion certificates. * Contribute to the training and proficiencies of clinical personnel, including medical students and residents. * Maintain up-to-date training and certification in Basic Life Support. Professional : Nurse Practitioners are expected to act professionally in all aspects of their work and to be role models for the rest of the care team and staff. * Work collegially with other medical disciplines/mid-level providers, including sharing patient care and after-hours call. * Work collegially with the support and administrative staff in a positive, constructive manner. * Attend GPH staff meetings and other meetings as directed/requested by the CMO. * Participate in GPH activities such as health fairs, CME activities, and community events. * Comply with the GPH mission, values, and codes of conduct. * Follow GPH policies, personnel policies and established patient protocols, not otherwise addressed in Employee Handbook. * Perform other duties as assigned. STAFF EXPECTATIONS: * Support and show gratitude to all coworkers. * Agree to ask for help when needed and ask questions to learn; be willing to grow in your role and position at Greater Portland Health (GPH). * Be part of the solution. * Believe and participate in change and be willing to engage in improvement process. * Model effective teamwork and collaborative communication. * Provide respectful feedback (in a private setting) when encountering conflicts; ask for help from supervisor as needed. * Understand and value that every