Job Summary
The Continuing Care Nurse Practitioner will be responsible for the timely management of in basket functions for Geriatric and Palliative Care Providers unavailable for coverage due to, Palliative Care patient care (Home Based Palliative Care, Hospital, and Clinic) vacation, sick or other specified leave, as well as assisting with in basket management of select in basket folders, including patient emails, patient messages, and medication refill requests, at the direction of the Chief(s) of Service. The patient care plan should be initiated, as necessary, per department protocols. The Continuing Care Nurse Practitioner will review the medical record and address clinical needs, as appropriate, while adhering to The Southeast Permanente Medical Group, Inc (TSPMG) Nurse Protocols for Advance Practice Registered Nurses. Time will be allocated to patient visits, including telephone visits, integrated video visits, and face-to-face visits for appropriate conditions.
This is a full-time position that requires most of the work to be performed within the medical office buildings. The Continuing Care Nurse Practitioner may support multiple specialties, directly reporting to the Chief of Palliative and Geriatrics. The position will be a combination of in office work and virtual work and based at the Kaiser Permanente Gwinnett Comprehensive Medical Center located in Duluth, GA for outpatient clinic work. Candidate must be willing to be flexible.
Major Responsibilities/Essential Functions
• Seeing follow-up patients urgently (via TAV, IVV or in-person) when a new symptom requires immediate response.
• Following up on more stable yet frail Palliative and Geriatrics patients that require "light touch" for continued conversations about goals of care, disease education and planning.
• Refill Authorization Request (RAR) review and resolution to include ordering of appropriate lab work, follow-up office visits, prescribing refills, or other clinical needs as indicated in the care gaps listed in the medical record.
• Results (including referred results) review and resolution to include generation of letters, developing treatment plan, ordering of follow-up labs/radiologic studies, advising of follow up visits, or contacting the member via telephone encounter as appropriate.
• Ancillary orders pended for radiology or lab will be reviewed and signed as appropriate.
• Patient Messages, Patient Emails, and RARs will be reviewed and responded to with closure on the same day. Prescription orders may be placed and signed as appropriate.
• Patient emails will be responded to, and clinical advice given, per department protocol. The Continuing Care NP will proceed to address member requests within scope of practice, including sharing and managing results of labs/radiologic studies and placing referrals.
• Cancelled orders will be routed to the cancelled orders pool if routine and responded to if STAT/Timing Critical.
• Requests or need for narcotic orders will be forwarded to the On Call physician for signature - (DEA Licensed Drugs require approval from MD/DO or assistance with PharmD Protocol).
• Overdue Results messages will be reviewed and responded to as clinically appropriate.
• Medical Records will be reviewed with appropriate follow-up as needed.
• Future (approximately 6-12 months after hire) will train on geriatric protocols such as MOCA, SLUMS, basic geriatrics consultation procedures.
• Addendum notifications will be reviewed with appropriate follow-up as needed.
• As changes in KPHC, In-basket folders, staff responsibilities or other clinical needs arise, additional duties may be assigned.
• Fosters collaborative relationships with clinical staff and providers within the department.
• Builds and enhances efficiencies in In basket management for dissemination to all providers.
• Maintains superior member service orientation in all interactions.
• Documents in the medical record all clinical decisions, encounters, and orders.
• Knowledgeable and compliant with regional TSPMG personnel policies and procedures, as well as TSPMG clinical quality guidelines and workflows.
• Compliance with the TSPMG Nurse Practitioner Protocols will be maintained.
• Participates in annual regional and departmental compliance training.
• Develops and maintains an awareness of how to report compliance issues and concerns.
• Continuing NP may have the opportunity to provide direct patient care, both virtually as well as via face-to-face patient visits.
• Performs additional duties and responsibilities that support quality initiatives as assigned by chief.
• Regularly attends provider and department meetings.
Minimum Education and Experience Requirements
• Unrestricted current APRN license in the State of Georgia
• Master of Science in Nursing
• Qualified for NPI designation and Medicaid Provider ID
• Experience working with patients with complex medical, co-morbid and psychosocial problems.
• Demonstrated collaborative/team-oriented work style.
• Experience in data collection, review, and interpretation.
• Working knowledge of all federal, state, local and regulatory requirements, including Medicare/CMS
Preferred Education and Experience
• APRN Family or Adult Nurse Practitioner Specialty Certification
• One to three years of Nurse Practitioner experience preferred with at least one year of experience in Palliative Care and/or Geriatrics.
• Strong Health Connect/Epic Skills
Required Licensure, Certification, Registration or Designation
• RN & APRN license in the State of Georgia
• Willingness to acquire APRN Prescriptive Authority in the State of Georgia
• Certification from ANCC or AANP as a Family or Adult Nurse Practitioner