Nurse Practitioner - Care at Home - San Gabriel Valley

Astrana Health, Inc.•Monterey Park, CA

10h•$130,000 - $160,000•Hybrid

About The Position

We are seeking a highly skilled and compassionate Nurse Practitioner (NP) to join our Care at Home team. The ideal candidate will have expertise in managing patients with complex medical conditions in a home care setting, ensuring high-quality care for individuals who are considered high-risk due to chronic illnesses, multiple comorbidities, and complex healthcare needs. The Nurse Practitioner will work collaboratively with other healthcare professionals to deliver patient-centered care that focuses on keeping patients healthy at home throughout the San Gabriel Valley area, enhancing patient outcomes, and improving quality of life for homebound and complex patients. A significant component of the role will be providing supportive/palliative care to appropriate patients, ensuring symptom management and holistic support for those with serious illnesses. This position offers an exciting opportunity for a Nurse Practitioner to make a significant impact on the lives of patients with complex needs, providing care in the comfort of their own homes. If you are a dedicated, compassionate, and highly skilled healthcare professional, particularly with an interest in palliative care, we encourage you to apply. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team

Requirements

Current, unrestricted Nurse Practitioner license in CA and Furnishing License
Ability and willingness to travel to patient homes.
Ability to independently assess and manage patients in home settings with minimal supervision.
Excellent communication and interpersonal skills, with the ability to work collaboratively in a multidisciplinary team.
Ability to use electronic health records (EHR) systems and other clinical tools proficiently.
Knowledge of state and federal regulations governing home care services.
Strong critical thinking, problem-solving, and decision-making skills.
Ability to work with patients from various cultural backgrounds, ability to utilize translational services.

Nice To Haves

Proficient in Spanish preferred but not required.
Certification as an Adult-Gerontology Nurse Practitioner (AGNP) or Family Nurse Practitioner (FNP), with additional certifications or experience in relevant specialties (e.g., palliative care, wound care, gerontology) preferred.
Strong understanding of home health care protocols, chronic disease management, palliative care, and geriatric care.
Minimum of 3-5 years of experience in a clinical nursing role, with a focus on high-risk, complex patients (home care and palliative care experience preferred).
Experience in HEDIS and HCC
Speak Cantonese or Mandarin

Responsibilities

Conduct comprehensive health assessments, physical examinations, and diagnostic evaluations for patients in their homes.
Complete transitions of care post-discharge.
Develop individualized care plans for high-risk patients, considering their medical history, comorbidities, and functional status.
Prescribe and manage medications, including managing complex drug regimens for chronic conditions such as heart failure, diabetes, COPD, and more.
Perform health screenings and provide preventive care to help minimize hospitalizations and emergency room visits.
Assess patients for eligibility and appropriateness for palliative care, focusing on symptom management and quality of life for individuals with serious or life-limiting conditions.
Provide compassionate palliative care to improve comfort, alleviate pain, and address psychological, emotional, and spiritual needs for patients and their families.
Collaborate with the palliative care team to develop care plans that align with the patient's goals, preferences, and values.
Educate patients and families on palliative care options, including advanced care planning, pain and symptom management, and end-of-life care.
Monitor and adjust palliative interventions based on patient needs, ensuring a holistic approach to care that includes physical, emotional, and social well-being.
Collaborate with interdisciplinary teams, including physicians, social workers, care coordinators, and family caregivers, to provide holistic patient care.
Ensure effective communication and care coordination between the home care team and any specialists involved in the patient’s care.
Serve as a primary point of contact for patients and their families, providing education, support, and guidance as needed.
Monitor and manage high-risk conditions in collaboration with the patient's care team, with a focus on chronic disease management and health promotion.
Educate patients and families on disease management, symptom control, medication adherence, and lifestyle modifications.
Review patient records regularly and update care plans to adjust to changing conditions or new diagnoses.
Accurately document all patient interactions, assessments, treatments, and progress in the Electronic Health Record (EHR) system.
Maintain confidentiality and comply with all relevant healthcare regulations and standards (e.g., HIPAA).
Participate in team rounds on patient progress, interventions, and outcomes.
Advocate for patients’ rights and ensure that they receive the best possible care and services in the home setting.
Address any concerns or challenges that arise in the home care environment, ensuring patient safety and satisfaction.
Support patients and families with end-of-life planning, palliative care needs, and grief counseling when appropriate.
Other duties as assigned.