- Conducts thorough assessments of members identified as having Palliative Care needs including but not limited to: accurate history and physical assessment, medication reconciliation, goals of care identification, psychosocial/spiritual needs assessment, symptom management identification and plan
- Determines and documents appropriate follow-up plans in line with member goals and communicates these plans with member and caregivers
- Completes ACP documents as appropriate
- Reviews and includes the most appropriate diagnosis codes, in addition to correct billing and procedure codes.
- Engages other team members to help address needs of members, through participation in family meetings or referrals as needed
- Collaborates with and provides recommendations for outside Documents these suggestions and contacted providers
- Provides oversight and coordinates prescriptions and delivery for members on service with Collaborative Care Partners and end of life panel
- Completes documentation within 24 hours of visit
- Engages with outside providers in a meaningful, partnership-driven Identifies and suggests opportunities for education that may help further understanding of Palliative Care tenants to continue engagement.
- Participates in multidisciplinary team meetings and works towards Palliative Care strategic objectives
- Mentor and coach new staff as requested
- Problem-solves local issues and engages in professional conflict management
- Identify and communicate opportunities for operational improvement under direction of Palliative Program Manger to improve the performance of CCA
- Assesses appropriateness of incoming requests and team's processes over time to suggest opportunities for improvement
- Participates in work groups as requested for process or service delivery improvement
- Provides education to stakeholders as requested
- Shows an ongoing commitment to learning about the tenants of Palliative Care through ongoing pursuit of education
- Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
- Master's Degree in Nursing
- Certified in Basic Life Support for Healthcare Providers
- Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in
- Demonstrate clinical competence in all aspects of primary care, care management, assessment, care planning, diagnosing and coding
- Excellent interpersonal skills demonstrated by ability to interact professionally with culturally and educationally diverse staff and patients
- Experience with electronic medical records preferred
- Experience working with Medicare /Medicaid populations or populations with significant complexity of medical, behavioral and social
- Ability to manage significant change
- Excellent communication skills
- Ability to teach, mentor, and coach
- Ability to quickly shift gears and move in a new direction without clear guidance
- Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
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Palliative Care Nurse Practitioner - Boston, MA, United States - Commonwealth Care Alliance
Description
The Palliative Care NP provides consultative specialty services related to serious illness impacts on members and caregivers and care coordination to a defined panel of CCA member's needs.
The panel of members will be comprised of individuals with serious illness and may have significant behavioral, psychosocial and medical complexities that require intensive clinical support (in addition to that provided by the member's primary care provider) that help decrease barriers to fully and successfully accessing the health care system.
The Palliative Care NP is the part of a team responsible for the clinical, behavioral health, and care coordination related to serious illness for their panel of membersResponsibilities include:
care coordination with internal and external providers, liaison with other relevant providers around medical, chronic disease, behavioral health and long-term service and support needs, and the provision (with support) of end of life/palliative care, as needed.
Role also includes a compendium of care coordination functions encompassing the development and implementation of the member-centered individualized care plan inclusive of correct identification/ coding of diagnosis related to serious illness.
The Palliative Advanced Practice NP provides clinical oversight of members referred to Palliative Care. The Palliative Advanced Practice Manager reports to the Palliative Program Manager, with clinical oversight by the Palliative Director (MD).Preferred:
Hospice and Palliative Care certification
Required Experience
3+ years practicing in Hospice, Palliative care or end of life care setting
Preferred:
Experience caring for patients/members facing end of life with complex medical, behavioral health, and social needs strongly preferred.
Required:
Required:
English
Preferred:
Spanish
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