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Point32Health Sr. Nurse Practitioner (Direct Care NP) - Melrose and Wakefield, MA territory in Canton, Massachusetts

"Who We ArePoint32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.Job SummaryPlease note - this role will be local to Melrose, Wakefield, and nearby cities/towns in Massachusetts Under the direction of a Senior Manager, the Nurse Practitioner (NP) in the Community and SNF/ Post-Acute Program will see high risk members in the home in addition to providing post-acute oversight in identified skilled nursing facilities where needed. This is a hybrid position that focuses on advanced level interventions during transitional engagement points with an aim to improve outcomes and quality of care for a specific cohort of patients. This care is provided predominantly in the community where the NP will use his/her advanced practice skills to evaluate the older adult patient and provide medical management and counseling on disease processes unique to the geriatric/adult population.This care is performed in conjunction with local area medical groups as well as in collaboration with care management teams and a nurse practitioner rounder. The NP in this role is responsible to build and foster these essential relationships with an aim to improve coordination of care as it relates to transitions of care and re-admission mitigation.Key Responsibilities/Duties - what you will be doingTransition of Care VisitsPost hospital visits for high risk members in the community following an acute rehab stay or discharge from an acute facility in which additional support from an advanced clinician will reduce readmission risk and improve clinical outcomesAdvanced clinical support for members defined as high risk based on multiple re-admissions, high disease burden, progressive disease presentations (COPD/CHF) or limited access to care within a defined geographical regionPerform strong medication review and reconciliation with education to family and patient to improve understanding and complianceEngage and implement practices that improve continuity of care and secure primary care communication and follow upEnhanced level of care coordination with community providers and case management to assure strong clinical care plan as it relates to presenting condition with a focuses on collaboration and consistencyDevelop and ensuring a plan of care is in place, including anticipatory guidance and planningFacilitating access to appropriate support models of care i.e. hospice, rehabilitationProviding education and coaching to the member, family, and/or caregiver about health status, treatment options, disease trajectories and goals of careDemonstrate exceptional communication and collaborative skills with all care team members that will improve the care and outcome of the member and support ongoing medical, emotional, and functional needsSNF ResponsibilitiesThe NP in this role will at times be required to cross cover and co-manage patients in the post-acute setting. These patients will be identified as a specific member cohort and the nurse practitioner will collaborate with other rounders to primarily manage the patient during a skilled event and facilitate discharge planning back to the community.Qualifications - what you need to perform the jobEDUCATION: (Minimum education and certifications required)Graduate degree from an accredited school of nursing and nurse practitioner program.Certified nurse practitioner through ANCC/AANP for adult, family, acute c re and/or geriatrics (GNP preferred)Current Massachusetts State licenseCurrent Drug Enforcement Administration (DEA) registrationCurrent Massachusetts Department of Public Health (DPH) Controlled Substance Registration (CSR)EXPERIENCE: (Years of experience)Minimum of 2-3 years of experience working with the frail or elderly population requiredMedicare and Medicaid experience preferredExperience with computer systems, including web based applications, electronic medical records and some Microsoft Office applications (Word, Excel)SKILL REQUIREMENTS: (Include interpersonal skills)Strong communication and human relationship skills are required to work with variety of medical, nursing, and allied health personnel as well as with patients and their families.Ability to exercise judgment and raise issues appropriatelyAbility to work cooperatively as a team memberStrong attention to detailWORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime)Work is performed at skilled nursing facilities and at times in the community setting. Normally there is appropriate lighting, ventilation and good working conditions. Some exposure to medical devices, and related equipment. When traveling outside the facility, subject to normal conditions (weather, traffic, etc.)Ability to speak clearly, see and hear individuals.Able to operate a motor vehicle, telephone and computer keyboard.Ability to travel within a facility or to other facilities or related locations.A valid driver's license and access to an automobile for travel is required.Occasional lifting of materials/ability to carry supplies of up to 20 poundsCOVID PolicyPlease note: All Direct Clinical Care Employees must be fully vaccinated against COVID-19, unless they obtain an exemption/accommodation pursuant to Point32Healths process. As of August 31, 2023, all Direct Clinical Care Employees must be up to date on their COVID-19 vaccination, unless they obtain an exemption/accommodation pursuant to Point32Healths process.#LI-MB1#LI-HybridCompensation and Total Rewards OverviewAs part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Companys sole discretion, consistent with the law.Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:Medical, dental and vision coverageRetirement plansPaid time offEmployer-paid life and disability insurance with additional buy-up coverage optionsTuition programWell-being benefitsFull suite of benefits to support career development, individual and family health, and financial healthFor more details on our total rewards programs, visit to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health EquityPoint32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we dofrom product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.PDN-9ba1190f-6663-4c61-9c11-be975f6b81fc"