Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod.
Harbor Health operates two Programs for All-Inclusive Care for the Elderly (PACE) in Mattapan and Brockton, providing comprehensive healthcare, transportation and social services for more than 600 frail elders who continue to live with dignity and independence in the community. To help further the mission of Harbor, we are looking for a talented Geriatric Nurse Practitioner to join our Clinical Team.
We offer a comprehensive Benefits package including Health, Dental and Vision Insurance, up to $2500 in CME funds plus paid leave, reimbursement for license fees, generous Paid Time Off (PTO) plus 11 additional paid holidays and much more! Come join our great Elder Service Plan team!
Role:
The Geriatric Nurse Practitioner provides primary care services to Elder Service Plan-PACE (Program for All-Inclusive Care for the Elderly) participants in collaboration with the PACE physician. The Nurse Practitioner manages acute and chronic illnesses; provides routine preventative and health management services; and makes appropriate referrals for medical and non-medical conditions; and collaborates with the PACE interdisciplinary team. Position is based at the Elder Service Plan (ESP), 1135 Morton Street in Mattapan, MA.
Key elements of PACE model of care include:

• Our Interdisciplinary Team manages the care of our frail elders and supports each other and the Elder Service Plan participants in achieving care goals in small patient panels (75 patients).
• Participants attend our center for Adult Day Health activities as well as receive on-site clinical care including primary care, behavioral health and rehabilitation.
• Our Nurse Practitioners follow our elders throughout all locations of care including sub-acute, long-term and home care settings; regular home visits are encouraged, and time is allotted for this effort.

Responsibilities:

• Provides primary care to PACE participants in collaboration with the PACE physician at the ESP site in Mattapan location, affiliated sites and in the participant's home as needed.
• Conducts health assessments and evaluates patient needs at the PACE center, assisted living facility, skilled nursing facility or participant's home.
• Participates in the development of a comprehensive plan of care for each participant.
• Participates in an on-call system with other providers to ensure 24-hour access to care for our participants.
• Participates in provider staff meetings, departmental meetings, general staff meetings, trainings, interdisciplinary team meetings and quality improvement activities.
• Makes appropriate, cost efficient referral decisions and refers primarily to contracted specialists; provides guidance and monitoring of systems necessary for the function of a capitated care program.
• Updates Electronic Medical Record (EMR) appropriately using proper coding and documents care accordingly; accurately and timely documents care in the medical record with progress notes, lab follow-ups, communications with participants; maintains a current problem list, medication flow sheet, immunization record and other appropriate information.

Requirements:

• MSN in Geriatric Nursing or related specialty field
• Current MA RN/NP license with current certification as a Nurse Practitioner; MCSR, DEA and current BLS (Basic Life Support for Health Care Provider) Certification
• 2 or more years of experience working with a frail or elderly population preferred, minimum of 1 year required
• Strong clinical, interpersonal and organizational skills
• Experience in working with an Interdisciplinary Team (IDT)
• Strong clinical, leadership, interpersonal and organizational skills
• Experience in the development and implementation of geriatric programs
• Familiarity with medications preferred, knowledge of community resources preferred
• Must be able to travel in a timely manner to ESP sites, patient's homes and affiliated sites as needed.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.