Care That Follows the Person—Not the Setting As a Nurse Practitioner in our PACE program, you’ll deliver relationship-based primary care to older adults with complex needs—partnering closely with an Interdisciplinary Team and supporting participants wherever they are (in the center, at home, virtually, or in skilled nursing settings). This role is built for clinicians who want meaningful continuity, whole-person care, and the time and team support to make a lasting difference. What Does Success Look Like? Show up as a core IDT partner: Serve as a member of the IDT, completing sections of assessments and care planning, and supporting Service Determination Requests. Own a panel with purpose: Actively grow and manage a panel of participants, building trust and continuity over time. Deliver high-quality clinical care (with appropriate approval): Initiate, evaluate, review, and change orders for medications, diagnostics, and treatments with approval. Coordinate care day-to-day: Assess, initiate, and coordinate care daily under supervision—keeping the participant’s whole picture in view. Document clearly and on time: Document participant interactions, assessments, and next steps in the EMR within center-defined timeframes. Connect participants to the right specialists: Make referrals and request consults as needed (with approval), ensuring follow-through and coordination. Practice comprehensive assessment and education: Perform histories and physicals, provide participant teaching, and support informed decision-making. Manage labs and follow-up: Order, interpret, and follow up on lab tests and results. Perform procedures within scope: Perform selected procedures as appropriate. Recognize risk early: Identify abnormalities and escalate concerns promptly. Collaborate across disciplines: Liaise with Behavioral Health, Pharmacy, and other team members to coordinate care seamlessly. Care wherever participants are: Evaluate and treat participants in the center, at home, virtually, in SNFs, and other settings as needed. Support goals and future planning: Facilitate advanced care planning discussions with participants and families. Strengthen documentation accuracy: Document chronic conditions via HCC capture.
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Job Type
Full-time
Career Level
Mid Level