Nurse Practitioner - ElderONE

Rochester Regional Health•Hudson, NH

39d•$100,000 - $150,000•Onsite

About The Position

Join ElderONE, Rochester Regional Health's comprehensive PACE (Program of All-Inclusive Care for the Elderly) program, providing integrated, person-centered care to older adults with complex medical, functional, and social needs. This Nurse Practitioner role offers the opportunity to make a meaningful impact by helping participants remain safely in their homes and communities while collaborating within a highly engaged interdisciplinary care team.

Requirements

MS: Nursing (Required)
NP - Nurse Practitioner Certification - NYS Office of Professions
RN - Registered Nurse - NYS Office of Professions

Nice To Haves

Passion for serving older adults and supporting nursing home eligible individuals to remain safely in the community
Experience working with older adults and/or medically complex patient populations
Experience in PACE, Primary Care, Long-Term Care, Home Care, Geriatrics, or community-based care settings
Knowledge of care coordination, value-based care, and interdisciplinary team-based care
Strong problem-solving, organizational, and relationship-building skills
Epic experience
PACE experience

Responsibilities

Evaluate and manage acute, sub-acute, and chronic clinical needs of older adults.
Collaborate with physicians and interdisciplinary team members to develop individualized treatment plans that align with participant goals, functional status, and quality of life.
Complete comprehensive clinical reviews of chronic conditions and document in the medical record.
Assess and reassess participant-specific goals of care while reviewing specialty recommendations and coordinating appropriate follow-up care.
Attend daily interdisciplinary team meetings and care planning conferences.
Review laboratory results, specialty notes, and diagnostic testing, initiating orders when appropriate.
Complete pre-enrollment visits and support care transitions and discharge planning activities.
Support approximately 800+ ElderONE participants across multiple community-based sites and home settings.
Partner closely with Primary Care, Home Care, Extended Care, and other system services to provide coordinated, person-centered care for a complex older adult population.
Contribute to a growing and evolving PACE program through interdisciplinary collaboration, quality improvement efforts, process enhancements, and innovative approaches to care delivery.
Utilize infection control equipment and safety guidelines to minimize and prevent exposure to communicable diseases, infectious body fluids, and risks associated with patient treatment.