Job Description:
That’s Right!.. Fantastic work setting working in an elder adult day setting –Practical Monday to Friday Work week!Predictable 8:00 to 5:00 Day Shift!No Nights, No Weekends, No On-Call! Quality over Quantity Care Setting!Great Mentoring with Physicians and Opportunities to Work with Students!PACE is a Growing Area of Health Care, Come Grow with It! About Summit ElderCare: Offered by Fallon Health, we are the only program of its kind in Central Massachusetts and is one of eight PACE programs (Program of All-Inclusive Care for the Elderly) in the State. Summit ElderCare© provides a combination of medical, social and insurance services using an interdisciplinary team approach to help older adults avoid nursing home placement. Summary: Manages a primary care panel of participants and provides continuity primary health care to PACE participants that reside in the community or long-term care setting with a focus on goal oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant’s goals of care. Works in close collaboration with all members of the PACE Interdisciplinary Team.Establishes realistic goals and helps develop and manage individualized plans of care with the IDT team for program participants.Provides primary health care to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a participant-focused manner focusing on what matters most.Works in close collaboration with the program’s interdisciplinary team to establish realistic goals and care plans and develop and manage individualized plans of care for program participants. Responsibilities:Performs post enrollment visits, biannual exams of participants and appropriately identifies and documents problems/issues in medical recordsEvaluates episodic illnesses and issues appropriate diagnostic and therapeutic ordersCollaborates with physicians and other interdisciplinary team members to manage episodic and chronic medical needs of participantsAddresses and documents Advance Directives/MOLST discussion for participants a minimum of annually and when a change in participant condition occurs Performs diagnostic, therapeutic and nursing intervention as indicatedProvides continuity in monitoring of chronic, stable illnessesImplements the participant plan of care in a safe and effective mannerParticipates in interdisciplinary team meetingsEvaluates effectiveness of previously implemented treatment Conducts home and nursing home visits as indicatedMaintains accurate documentation and coding of all services provided according to professional standards Identifies utilization and service delivery problems and participates in identifying a resolutionIdentifies grievances and brings forward to leadershipParticipates in quality assessment activities including but not limited to record reviews, outcome measurement and review/revision of policies and proceduresProvides education and training to participants, caregivers and staff in relevant topicsActs a resource to program staff and participates in defining care standards and practicesServes on appropriate committees, participates in all site and provider staff meetings including behavioral rounds and psychiatric rounds as indicated.Enhances personal professional growth and self-development through participation in professional activities including educational programs, current literature, in-service programs, trainings and workshops. Maintains BLS certification and professional certification as appropriate.May be asked to perform other duties that align with Fallon Health’s mission, including but not limited to participation on clinical committees, providing education, quality initiatives and/or other activities. Qualifications:Master’s degree required. Graduate of an accredited Nurse Practioners programLicensed by the Commonwealth of Massachusetts Board of Registration in Nursing. One to three years of Nurse Practitioner experience preferred with at least one year of experience in geriatric care.Experience working in a healthcare setting as a member of a professional clinical team.Experience with care coordination. About Fallon Health Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit COVID-19 Vaccination: With the end of the Global Coronavirus COVID-19 Pandemic, Fallon Health no longer requires all employees to be vaccinated against COVID-19 except for employees who are in jobs that under state and federal laws, regulations and policies are required to be vaccinated and/or they are in Member/participant facing positions. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.