Report to: VP of Operations
GrayHawk Home Care aspires to consistently be known and valued for providing the highest standard of in-home care services; for being the provider-of-choice in the community and for being the employer-of-choice in the community.
Position Summary: Work with collaborative physicians and clinical team to identify high risk patients and develop an advanced plan of care based on physical, psychological and social needs. Assess health behaviors, identify health risk indicators and make appropriate referrals to members of the clinical care delivery team. Determine which patients are within agreed upon scope of service and which patients should be managed only through face to face vs. telehealth visits with PCP or sub-specialist. Coordinate care from acute and post-acute care facilities to home. Complete in-home multimorbid assessments Optimize care plans and ensure discharge instructions are clearly articulated. Educate patients and families and assist them in assuming responsibility for reducing further exacerbation of their health status as well as improving their overall health goals.
Communicate, consult and collaborate with physician partner in the delivery of quality patient care protocols and practices; with the aim of reducing hospital readmissions. Work to minimize fragmented care within the care delivery system to ensure all services provided to patients are seamless and efficient.
Work with administrative team to comprehend and manipulate Electronic Health Record management system (EHR). Understand all related CPT codes and ensure documentation requirements are consistently above standard.
Performs duties in support of the GrayHawk Home Care’s mission to ensure the highest quality of patient care in an economically sound and efficient manner.
Age range of patient populations served: Primarily Geriatrics
- Functions to the full level of the NP/PA license as a member of a multidisciplinary care team to provide age appropriate, high quality health care as appropriate to the patients receiving Transitional and Chronic Care Management services
- Performs home visits as required. Completes full assessment of patient including physical exam and evaluation of all medical conditions, assessment of home environment and medication review. Addresses any issues identified during the course of the visit
- Differentiates normal aging from illness and disease processes and uses standardized assessment processes to assess social support and health status such as cognition, mobility, pain, skin integrity, quality of life, nutrition, neglect and abuse
- Work closely with care team, patients and families to assess risk for rehospitalization and implement individualized interventions to minimize the risk and develop strategies to reduce hospital readmission
- Identify need and frequency of visits based on patient’s health status and articulate need to social work /nurse Health Coaches as deemed appropriate
- Collaborates with physician partner when needed to address optimal care plan for patients with multiple morbidities
- Work with the Care Coordination team to identify ED Visits, Observation, or all levels of inpatient admission to ensure patients receives an updated Transitional Care Management assessment
- Understand EHR system and documents all patient contacts in a timely, accurate and structured manner
- Demonstrates accuracy in billing as evidenced by successful completion of annual billing and coding modules and internal compliance audits
- Works with the team to track data and develop quality metrics to ensure efficacy and improve outcomes
- Demonstrates cultural competence in all interactions with patients, caregivers and other members of the team. Provides care that is respectful of and responsive to cultural and linguistic needs.
- Meets department productivity and quality goals. Identifies and reports any barriers to achieving these goals
Education and Training
Current licensure to practice as a Certified Registered Nursing practitioner or Physician Assistant in the Commonwealth of Pennsylvania.
3 years clinical experience as a professional nurse or related clinical experience.
- Experience in Geriatrics is desired
- Experience ibn home Care is desired.
- Registration, Licensure and/or Certification:
Skills: Competencies in key elements of nursing care
- Ability to work with a diverse population
- Flexibility and Adaptability
- Good collaborator
- Critical Thinking and Reasoning
- Effective Communicator
- Possess Empathy
- Strong Interpersonal skills
- Knowledge of trends in nursing care
Physical Demands and Sensory Requirements:
- Moderate physical effort: lift/carry up to 10-30 lbs.
- Balance of sedentary/mobility work
- Frequently kneeling/crouching/reaching
- Occasionally lifts equipment/supplies
- Manual dexterity
- Frequent stooping/bending
- Frequently handles/lifts/pushes patients
- Hearing sensitivity bilaterally within normal limits (0-24.db HL) aided/non-aided and/or visual acuity of 20/60 in at least one eye (with/without correction)
- Ability to communicate verbally
- Biohazardous substances
- Infections/contagious diseases
- Infectious specimens
Environmental Conditions & Blood Borne Pathogen Risk:
- Category I. Routine tasks involve exposure to blood, body fluid or tissues.