OverviewProvides clinical leadership to promote increased compliance with a range of quality and cost measures and standards of care. Manages service delivery of inter-professional and para-professional team members working on an individual case or population of cases. Acts as a key resource in providing clinical and operational guidance and support to assigned teams and other staff to achieve and enhance team outcomes. Provides advanced nursing clinical care for patients in accordance with current State and Federal rules and regulations for nurse practitioner's scope of practice and national standards of care. Works under the supervision of the Clinical Director for the Nurse Practitioner Program. • Manages and provides the full scope of advanced nursing practice for targeted patient populations, which may include short-term treatment of members at the point of care. Evaluates patient responses to therapy/interventions. Ensures revision of the inter-professional plan of care as necessary to achieve quality outcomes.
• Serves as the clinical authority on individualized care teams and leads rounds and interdisciplinary care team meetings.
• Manages and provides comprehensive, advanced nursing care, including post-discharge aftercare visits, annual comprehensive assessment visits, palliative care-care management program onboarding, and change in condition assessment visits (including physical examination, comprehensive history, screening for physical and/or psychological conditions, and point of care testing). Urgent interventions (i.e., escalations for the Care Teams, RPM, and the 24/7 Line), pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling, and patient education. Establishes a treatment plan based on clinical findings and determines when further evaluation by the collaborating physician, specialist, or emergency care is warranted.
• Collaborates with patients, families, primary care physicians and other team members to provide assessment and care planning. Assesses, plans, and provides intensive and continuous care management across client settings.
• Manages and provides clinical services in compliance with standards of Patient-Centered Medical Home standards, meaningful use of medical record data, HEDIS and QARR quality of care measurements.
• Manages inter-professional team efforts regarding the medical, nursing, therapy and ancillary care provided to patients to ensure quality outcomes are achieved.
• Participates in on call coverage schedule to ensure 24/7 access to practice clinicians.
• Assesses, educates, and improves client and caregiver knowledge of chronic disease, self-care management, and identification of changes in health status, including appropriate responses and actions through individualized education and inter-professional interventions.
• Observes and analyzes team performance patterns related to population under care and assists in developing interventions to improve team performance. Provides remedial support and guidance to interdisciplinary team members to address implementation/evaluation of plans that maintain/increase customer experience with care, cost-efficiency, and quality care compliance with regulatory standards.
• Communicates with internal and external care partners regarding the needs of the patient or population to ensure interventions occur in a timely and appropriate manner. Intervenes as needed when the care plan is not executed and remediates the situation to prevent reoccurrence.
• Performs procedures as outlined in collaborative practice agreement and as privileged by the Credentialing Committee.
• Manages quality of medical record documentation and submits billing information in accordance with Professional Corporation policy.
• Provides care in one or more care settings based on the clinical requirements: virtually, telephonically or travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options.
• Upon request, performs peer reviews of work performance, including quality of care, clinical documentation, coding and billing practices, communication skills, and population surveillance.
• May participate in the VNS Health Medical Care at Home Quality and Professional Advisory Committee and any associated workgroups related to development of evidence based clinical models of care, peer education and training, quality improvement, medical record configuration and reporting, maximizing the use of clinical decision support systems.
• May act as a preceptor for student Nurse Practitioners, providing excellent role modeling of community-based primary care practice.
• Assumes responsibility for continued professional growth, and maintains professional certification and licensure.
• For Psychiatric Nurse Practitioners only:
• Conducts psychosocial assessments of interventions patients and develops treatment recommendations. Determines whether further evaluation by a collaborating psychiatrist is needed.
• Provides the following services to patients: advocacy, psychoeducation, psychopharmacology, cognitive/behavioral interventions, monitoring of mental status, emotional support, brief psychotherapy and family-based interventions.
• Supports and educates VNS Health staff and caregivers to enable them to better care for patients with psychiatric, cognitive, and/or behavioral challenges.
• Consults with a collaborating psychiatrist as necessary to develop psychiatric evaluation and treatment plans.
• Consults with the referrer on assessment, recommendations, and updates on treatment progress.
• Follows treatment plans, revising and updating them as necessary, makes appropriate referrals for additional mental health services and provides crisis intervention as required.
• Participates in interdisciplinary team meetings, case conferences and clinical supervision; attends in-service education programs.
• Participates in special projects and performs other duties as assigned. QualificationsLicenses and Certifications: License and current registration to practice as a Registered Professional Nurse in New York State required
Certificate (license) and current registration to practice as a Nurse Practitioner in the State of New York, with a specialty in adult health, family health or gerontology required
Valid driver's license, as determined by operational/regional needs may be required
Maintains credentialed status with VNS Health Medical Care at Home and associated managed care plans required
Maintains NPI, Medicaid and Medicare provider numbers preferred
Maintains a collaborative practice agreement with a physician in compliance with New York State regulations preferred
Must be certified by ANCC or another accrediting Nurse Practitioner body – in order to bill Medicare and meet credentialing requirements required
For Psychiatric Nurse Practitioners only:
Current PMHNP-BC certification required Education: Master's Degree of Science in Nursing, or other graduate degree from a nurse practitioner educational program registered by the New York State Education Department as qualifying for NP certification (licensure) required
Current ANCC or AANP certification as an adult, family or geriatric nurse practitioner required
For Psychiatric Nurse Practitioners only:
Master's Degree in psychiatric-mental health Nurse Practitioner required
PhD in psychiatric-mental health Nurse Practitioner preferredWork Experience: Minimum of two years of experience as a nurse practitioner utilizing full scope of practice preferred
Clinical home care experience or two years managerial experience preferred
Demonstrated knowledge of Hedis and QARR quality measures, ICD-10 and CPT coding for reimbursement of services required
Bilingual skills, as determined by operational needs required
For Psychiatric Nurse Practitioners only:
Minimum of two years of experience as a psychiatric nurse practitioner utilizing full scope of practice required Pay RangeUSD $58.30 - USD $77.72 /Hr. About UsVNS Health is one of the nation’s largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.