APRN - LIbrus

Chapters Health System•Orlando, FL

49d•$92,721 - $139,081•Onsite

About The Position

It's inspiring to work with a company where people truly BELIEVE in what they're doing! When you become part of the Chapters Health Team, you'll realize it's more than a job. It's a mission. We're committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success! Role: The Librus APRN is a key clinical leader in the delivery of person-centered, value-based care to Institutional Special Needs Plans (ISNP), ACOs, and high-risk payors residing in Skilled Nursing Facilities, communities, or private homes. Working in alignment with the payor's model of care and under the Librus program, the APRN performs comprehensive clinical assessments, closes care gaps, participates in IDT meetings, ensures accurate HCC coding, reduces unneeded hospitalizations, and delivers high-quality primary and supportive care to medically complex patients. This role also includes providing end-of-life services, including comfort and symptom-focused care without formal hospice enrollment, ensuring quality of life and dignity are prioritized during serious illness and advanced aging.

Requirements

Licensed APRN with active certification (Adult/Geriatric NP, FNP, or similar) in the state of Florida.
DEA license with prescriptive authority.
Minimum 3 years of experience as a nurse practitioner, preferably in geriatrics, SNF, hospice, palliative care, or complex care management.
Demonstrated experience with HCC coding and risk adjustment models.
Familiarity with Medicare Advantage care gap closure metrics.

Nice To Haves

Experience with ISNPs, D-SNPs, or other value-based Medicare models.
Knowledge of SNF workflows and interdisciplinary care teams.
Comfort and skill in end-of-life conversations and palliative approaches.

Responsibilities

Serve as the primary advanced practice provider for assigned ISNP members, High-Needs ACO patients, and similar settings, delivering direct, evidence-based care in collaboration with facility and plan/payor staff.
Perform routine and urgent clinical assessments, diagnose and manage chronic and acute conditions, and adjust care plans.
Provide palliative and hospice-like care interventions focused on comfort, dignity, and patient-centered goals.
Conduct comprehensive annual and episodic assessments to ensure accurate capture of chronic conditions per CMS HCC guidelines.
Close quality gaps related to screenings, labs, immunizations, and chronic disease management per ISNP, Payor and plan metrics.
Maintain thorough, compliant documentation to support both care delivery and risk adjustment requirements.
Operate as a clinical champion of the Librus Model of Care, emphasizing proactive interventions, interdisciplinary collaboration, and reduced avoidable hospitalizations.
Partner with the RN Care Coordinator and facility teams to ensure service continuity, integration, and alignment.
Lead or participate in goals-of-care discussions, advance directive review, and shared decision-making with patients and families.
Support members through end-of-life transitions with empathy and skill, even without formal hospice enrollment.
Utilize comfort-focused prescribing and symptom management protocols.
Attend IDT meetings and collaborate regularly with payor physicians, SNF staff, and Librus leadership.
Communicate care plans effectively with patients, caregivers, and staff.
Submit timely and accurate clinical documentation, coding, and quality reporting.
Represent the Company professionally at all times through care delivered and/or services provided to all clients.
Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
Comply with Company policies, procedures and standard practices.
Observe the Company's health, safety and security practices.
Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
Use resources in a fiscally responsible manner.
Promote the Company through participation in community and professional organizations.
Participate proactively in improving performance at the organizational, departmental and individual levels.
Improve own professional knowledge and skill level.
Advance electronic media skills.
Support Company research and educational activities.
Share expertise with co-workers both formally and informally.
Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.