Job Description Summary

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The Primary Care Office Advanced Provider (Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) is responsible for and will provide total care for patients assigned in collaboration with the physician of record and members of the patient care team. The Advanced Provider (AP) must hold a license in good standing with the State of Florida. The AP will communicate and manage the patients’ care across all care providers, family, and caregivers. The AP will ensure that timely, patient-centered, appropriate evidence-based medicine is provided for patients with acute, chronic, and palliative care needs. The Advanced Provider will perform a patient assessment/exam, create a care plan, and provide intervention as indicated. The AP’s role includes diagnosing and deciding treatment for patients, analyzing and interpreting x-rays and lab results, writing prescriptions, taking patients’ histories, providing surgical assistance, and ordering home health, various therapies, and DME as indicated. The Advanced Provider will provide instruction and assistance on symptom management and advanced care planning for patients with chronic life limiting illness. The Advanced Provider will assist in addressing outstanding Quality Measures and HCCs as applicable to meet or exceed all quality goals. The Advanced Provider will be responsible for ongoing communication with the Primary Care Provider to ensure continuity and coordination of care and is expected to consult with the supervising physician on any complicated diagnosis and treatment decisions. The Advanced Provider may work with regional Palliative/Hospice Care agencies to facilitate end-of-life care and services when appropriate. The Advanced Provider will complete all documentation and billing in a timely manner, per protocol. Responsible for other duties as assigned.

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How Will You Make An Impact & Requirements

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Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Is responsible for the total care of all assigned patients in collaboration with the community-based physician/provider and patient care team.
• Is responsible for patient assessments and care planning, risk management plan development, addressing quality measures and HCCs, and providing acute interventions, chronic care management, and palliative care services within their scope of practice.
• Provides services to meet patient needs and prevent unnecessary Emergency Department utilization when appropriate. In home services may include but are not limited to: IV hydration, lab draws, nebulizer treatments, EKGs, wound care, injections and immunizations, and utilization of mobile diagnostics as indicated.
• Ensures all pertinent and active medical conditions are documented in the electronic medical record in a timely manner, consistent with Millennium Physician Group (MPG) policy, and in a compliant manner with Centers for Medicare & Medicaid Services (CMS) and other insurance carriers.
• Exhibits strong clinical skills to improve patient care for an aging, adult population; as well as excellent interpersonal relationship skills in interpreting and communicating health care information to the patient, family, and patient care team.
• Provides leadership in the application of the nursing process to client care, organizational processes and/or systems improving outcomes at the program or service level and initiates interdisciplinary projects to improve organizational performance.
• Identifies patients who are appropriate and would benefit from skilled nursing/therapy and initiates appropriate process for qualifying value-based patients. Follows all CMS guidelines and ensures patient is admitted to a qualifying SNF. Completes all required documentation and works with other members of the health care team to ensure continuity and patient safety.
• Instructs and counsels patients regarding compliance with prescribed therapeutic regimens and health maintenance.
• Accountable for identifying patients needing additional assistance and making referrals to home care, social services, behavioral health, and other available community resources, when needed and appropriate.
• Works collaboratively with Program Manager in oversight of assigned Medical Assistant and to establish workflow processes, provisions of ongoing education/training, and employee improvement planning as needed.
  
  

Supervisory Responsibilities

This job has no direct supervisory responsibilities. May indirectly oversee assigned Medical Assistant and work in collaboration with the Post-Acute Manager.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Analysis/Problem Assessment – Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.

Compassion - The responsibility to put a patient’s or person’s interests first, including the duty not to harm, deliver proper care, and maintain confidentiality.

Compliance - Employee has satisfactory completed employers required compliance training. Employee is able to demonstrate an understanding of employers Code of Conduct.

Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.

Dependability - Meets commitments, deliverables, deadlines, work independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, and meets attendance/punctuality requirements.

Individual Leadership/ Influencing - Using appropriate interpersonal styles and methods to inspire and guide individuals (fellow employees) toward goal achievement; modifying behavior to accommodate tasks, situations, and individuals involved.

Innovation - Generating creative solutions to work situations; trying different and novel ways to deal with organizational problems and opportunities.

Integrity - Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities.

Judgment/ Problem Solving - Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others.

Maximizing Performance - Establishing performance/development goals, coaching performance, providing training, and evaluating performance.

Energy – Consistently maintaining a high activity or productivity level; sustaining long work hours.

Humility/Respect – Being courteously respectful of others. Awareness of oneself in relation to others, having a clear perspective and respect for one’s place in context and of others.

Organizational Awareness - Having and using knowledge of systems, situations, procedures, and culture inside the organization to identify potential organizational problems and opportunities; perceiving the impact and the implications of decisions on other components of the organization.

Patient Service Orientation - Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence.

Planning and Organizing/ Work Management - Establishing a course of action for self to accomplish a specific goal, planning proper assignments of personnel and appropriate allocation of resources.

Results Driven & Execution – Is attentive to detail and accuracy, is committed to excellence. Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative.

Teamwork/ Collaboration - Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions.

Work Standards - Setting high goals or standards of performance for self, direct reports, others, and the organization; being dissatisfied with average performance; self-imposing standards of excellence rather than having standards imposed by others.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience – Completion of master’s degree in nursing; two or more years related experience and/or training preferred; or equivalent combination of education and experience.

Language Skills - Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints.

Mathematical Skills - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills - To perform this job successfully, the individual must be computer literate with good computer skills. The individual should have knowledge of Athena Database software; Microsoft Spreadsheet software and Microsoft Word Processing software; including Excel with ability to learn additional computer programs as required.

Certificates, Licenses, Registrations

Current active Florida License as an Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) required. CPR/BLS certifications preferred.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to sit. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. In Home patient visits is a requirement of this position. While performing the duties of this Job, the employee is exposed to outside weather conditions and patient’s home environment.