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The Alignment Care Anywhere program is a physician-led and advanced practice clinician-driven program that is intended to care for and support Alignment Healthcare patients by proactively providing an additional level of medical and social support in the comfort of their home, which includes private residences and long-term care facilities. This program is expanding the locations where it provides patients with medical and social support when and where they need it, with the goal of preventing unnecessary hospitalizations, health complications, and unmanaged disease progression that can occur when timely clinical interventions are not provided or are not accessible. Our home-based programs are offered to eligible patients at no cost to them.

Immediate opening for a Nurse Practitioner or Physician Assistant to travel to local skilled nursing facilities.  You would see approximately 10-15 patients a day depending on the daily census.

Position Summary:

An exempt clinical position where the nurse practitioner (NP) or Physician Assistant (PA) is responsible for providing direct patient care. The NP participates as a leader of the skilled nursing facility (SNF) care team. Visits Alignment members/patients at skilled and long-term levels of care in designated SNFs facilities.  Provides appropriate evidence-based geriatric medicine. Coordinates care with hospitalists, primary care physicians and care managers. Makes home visits as directed by the medical staff to meet patient needs and provide continuity of care.

ESSENTIAL JOB FUNCTIONS

• Maintains privileges in multiple Nursing Homes
• Consults supervising attending as needed
• Documents patient visits electronically at least 90% of the time
• Participates in documentation and other quality improvement programs
• Available via phone weekdays 8am- 5pm and when on call.
• Will reviews, approves, and modifies admission orders
• Creates a detailed admit note for each admission within 24 hours of patient admission to SNF, including medication reconciliation
• Initiates/documents Advanced Directives/POLST form
• Determines if Health Care Proxy status is correct and invoke if appropriate

Daily Visits

• Initiates and review orders, including medications, on a daily basis
• Reviews labs, radiology reports, and consults on all patients
• Talks to and examines each assigned skilled-level patient on daily rounds Monday through Friday
• Writes at least one daily progress note for each skilled patient
• Assess patient's medical stability daily. Consults/coordinates with specialists as needed
• Addresses acute mental status changes via non-pharmacologic or pharmacologic measures, consultation or transfer
• Coordinates/assess rehab progress on a daily basis
• Discusses concerns with the patient, family, rehab, and case management.
• Educates patient and family members regarding acute and chronic illness management
• Attends family meetings as necessary
• Assists PCP's that participate in SNF management
• Informs attending and/or ACA medical director of significant changes in medical condition
• Participates in weekly utilization meetings, collaborating with the SNF care team and ACA care managers
• Coordinates with PCP's, Hospitalists, Medical Directors and Case Managers
• Performs home visits on selected patients
• Addresses /coordinates any legal issues.

 Discharge

• Develops a discharge plan utilizing input from case management and rehab.
• Identifies barriers to discharge
• Creates a detailed discharge summary for each admission on all patients, including medication reconciliation, and sends to the PCP at the time of SNF discharge
• Ensures that patients have all appropriate drug and DME prescriptions at discharge
• Coordinates visits with the PCP post-discharge
• Discharges summary to be sent to the PCP at discharge
• Updates all patients before discharge
• Coordinates transition from skilled to long term placement.

 Long-Term Care

• Assists case management in the evaluation of selected long-term care patients
• Follows "new" long term patients every 30 days
• Assists the attending physician with management for complex long-term patients
• Works closely with AHC clinical leaders, regularly discussing any concerns regarding utilization of services or complicated cases.  
• Collaborates with PCPs, IPAs, and external and AHC Case Managers to develop care plan for members.
• Performs diagnostic and/or therapeutic procedures within his/her level of training and expertise, and as outlined on the practice agreement and written protocol with the supervising Physician.
• Orders, interprets and evaluates diagnostic tests to identify and assess patients' clinical problems and health care needs.
• Discusses case with CAW Physician leaders when appropriate.
• Prescribes medication or other forms of treatment as indicated.
• Use of Electronic Medical Records required.
• Local travel is required; travel to AHC's corporate office in Orange, CA is required for perioding management/program training.

Minimum Requirements:

Minimum Experience:

• 2+ years of clinical nursing experience preferred, including work in a skilled nursing facility.
• Minimum of 1-year experience leading clinical staff, preferably within a high-risk clinic and/or home-based care delivery environment.
• Current unrestricted state license and current state driver's license
• Knowledge of CPT, ICD-9 and HCPC codes
• Knowledge of clinical standards of care
• Awareness of UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems, is helpful
• Passion for geriatric patient care
• Comfortable with providing home-based care/home visits

Education/Licensure:

• Active California state license as a Nurse Practitioner/Physician Assistant
• Active Nurse Practitioner/Physician Assistant Board Certification
• Medicare Part D Prescriber
• Valid California driver license and current automobile insurance
• NP (Nurse Practitioner):
• Active RN License (Must, upon hire)
• Active NP License (Must, upon hire)
• Furnishing number (Must, upon hire)
• NPI Number (Must, upon start)
• DEA Number (Must, within 6 months of start)
• Board Certification: AANP, ANCC (Must, within 6 months of start)
• Valid BLS (Basic Life Support) (Must, upon start)
• Valid ACLS (Advanced Cardiovascular Life Support (Preferred)
• PA (Physician Assistant):
• Active PA License (Must, upon hire)
• NPI Number (Must, upon start)
• DEA Number (Must, within 6 months of start)
• Board Certification: NCCPA (Must, within 6 months of start)
• Valid BLS (Basic Life Support) (Must, upon start)
• Valid ACLS (Advanced Cardiovascular Life Support (Preferred)

Other:

• EMR experience is strongly preferred.
• Must be able to work a flexible schedule and travel as needed.
• Preferred Qualifications:
• Experience in gerontology, adult care
• Home care or home visit experience
• Excellent administrative, organizational and verbal skills
• Effective communication skills with seniors
• Ability to work independently
• Detail-oriented
• Dependable and reliable

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.