Chronic Care Nurse Practitioner
Chronic Care Nurse Practitioner
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Job Description
HWP is focused on providing chronic care management (CCM) Remote Patient Monitoring (RPM) and Transitional Care Management (TCM) services to patients through our novel service offering. HWP services patients independently through direct referrals and also through agreements with other providers as an outsourced clinical vendor.
Under the direction of our Clinical Practice Leader the Chronic Care Nurse Practitionerisresponsible formeeting with patients virtually and creating a clinical care plan for patients to be carried out by our clinical staff. Additionally this role will direct clinical staff to appropriately escalate patient clinical concerns and make clinical decisions related to patients care.
This position offers the flexibility of a hybrid work environment and is 40 hours per week.
What Youll Do
- Meet with referred patients virtually on initial visits to identify a patient problem list and document a care plan to help the patient better manage their chronic disease states
- Recommend Remote Patient Monitoring and other services to the patient as needed to ensure HWP provides value for the patients ongoing management of chronic conditions
- Document all encounters in our EMR software (athenahealth)
- Functions as a liaison between patients and their care team to improve communication and patient care.
- Coordinates medical care for patients including patient education program enrollment appointment management coordination of on-going diagnostics medication adherence and adverse effect monitoring and provider communication.
- Work with our MAs/CNAs/ non-licensed staff by directing them on best practices to resolve a patients clinical issues including assessing appropriate escalation pathways for concerns as necessary.
- Communicates with the HWP Clinical Practice Leader and healthcare providers as appropriate to ensure timely communication about patient care and concerns.
- Initiates monitors and coordinates care planning for assigned patients
- Prepare documentation on visit as appropriate to determine correct billing codes
- Achieves monthly goals for billed coordination services or provides real time feedback into why goals were not achieved.
- Provides a significant amount of patient/family education regarding the patients disease states including proper monitoring and care
- Communicates in a caring and professional manner with patients staff and physicians.
- Actively advocates for patients to improve their healthcare experience and treatment outcomes.
- Partner with the patients care team to drive clinical outcomes including reducing admissions and hospitalizations
- Participate in continuing quality improvement activities for all staff including identifying and resolving opportunities for staff education and process improvements
- Demonstrate excellent interpersonal skills to relate to healthcare personnel proven success in working cooperatively and collaboratively to resolve problems as well as effectively communicating within and outside of the department.
What Youll Need to Succeed
- Current valid MA Licensed APRN License
- Independent Practice Authority in Massachusetts is preferred but not required
- Willingness and ability to acquire other state licenses as required by business need
- Registration with MassHealth and Medicare (PECOS) preferred
- 1-2 years experience in a primary care/internal medicine/ case management role working with patients with chronic disease states
- Creativity to drive rapid change and improvement in HWPs service offering to patients by providing high quality care and care team enablement
- Experience with delivering care to patients virtually preferred
Make A Difference With HWP
HWP is a new approach to care management and care team enablement. Working directly with the patients pharmacy and care team we fill the gaps in a patients care by providing high quality virtual health care services for chronic disease states with a team of clinicians. With a focus on medication management and a built-in relationship with a pharmacy partner we work with our patients to offer advice on how to live best with their chronic disease states and through objective and subjective data collection detect issues before they lead to bigger concerns.
We prioritize the health and well-being of our team members at HWP. We offer medical pharmacy dental and vision insurance plans ensuring that our employees and their families have access to quality healthcare services to maintain their overall health and wellness. We offer a 401(k) plan with a generous company match empowering our employees to save for retirement. We understand that life is full of unexpected twists which is why we offer employer covered comprehensive short- and long-term disability and life insurance. We also offer 10 company holidays and have a generous paid time off policy to support work life balance. Our quarterly and end of year employee core value awards during company sponsored events uses recognition to foster a positive work culture. Additional benefits include an employee assistance program voluntary life AD&D and accident coverage for employees spouse and child identity theft detection coverage employee referral program and educational reimbursement.
HWP is an Equal Opportunity Employer. HWP does not discriminate on the basis of race creed color religion national origin sex sexual orientation gender identity age physical or mental disability or any other basis covered by appropriate law. All employment decisions are made on the basis of qualifications merit and business need. HWP is committed to providing reasonable accommodations for qualified individuals with physical and mental disabilities in our job application procedures. If you need assistance or an accommodation due to a disability you may contact us at We will make a determination on your request for reasonable accommodation on a case-by-case basis.
Employment Type
Full-Time
