SKILLS & COMPETENCIES
- Practices the WellBe mission: To help our patients lead healthier, meaningful lives by delivering the most Complete Care.
- Partners with other clinicians in the “Care Community managing the health and wellbeing of patients living in their homes.
- Responsible engaging attributed patient into WellBe program
- Provides primary care to patients in the home
- Facilitates staff, patient, and family decision making by providing educational resources.
- Performs initial patient screenings/physical examinations creates appropriate assessment/plan
- Addresses urgent care needs of the patients as needed
- Collaborates with community team to complete care assessment
- Orders, interprets, and analyzes diagnostic tests and determine the need for follow-up appointments and further treatment options
- Prescribes and manage medications and treatments as appropriate, including but not limited to psychopharmacological agents
- Updates patient records and check records for accuracy at each patient appointment
- Delivers quality care while maintaining all company metrics pertaining to appropriate documentation/coding, HEDIS measures, engagement of patients, and managing medical expense.
- Serves as a resource for patients in delivering ongoing care information, counseling and guidance for any patients with critical conditions
- Refer to internal/external resources as appropriate such as WellBe behavioral health protocols
- Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings
- Maintain required licensure and certification
- Deliver palliative care, and when needed, end of life care to patients and families
- Facilitates family meetings with WellBe community team, to help with complicated family dynamics and goals of care
- Other tasks needed to accomplish team’s objectives/goals
Educational/ Experience Requirements:
- Minimum Master’s Degree in Nursing
- Valid nurse practitioner or physician assistant license in state of operations & current board certification in your field
- BLS and ACLS certified and an NPI# as an NP
- Have a valid driver’s license, car insurance, have access to a car and willingness to drive to patient homes/patient location, as well as an active auto insurance policy
Required Skills and Abilities:
- Must be familiar with EHR medical documentation
- Strong computer skills, including Word, Excel, and Powerpoint
- Strong verbal, written, presentation, and interpersonal communication skills
- Experience in Family practice, geriatrics, ICU, SICU, ER
- Palliative care, and end of life discussions/care experience
- Experience in motivational interviewing
- Must be able to diagnose and treat chronic and urgent medical/psychological conditions of older adults
- Home care experience preferred
- Ability to make knowledgeable clinical assessments and judgments
- Ability to provide counseling and emotional support with compassion and respect for the individual
- Ability to provide support to members of the care team
Supervisory Responsibility: This position will not have supervisory responsibility.
Travel requirements: Travel may be required up to 100% locally within assigned territory.
Work Conditions: Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. Ability to stand for extended periods. Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills/Visual acuity