at Point32Health in Chicago, Illinois, United States
Job Description
Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.
Job Summary
Under the direction of a Senior Manager, the Nurse Practitioner (NP) in the Community and SNF/ Post-Acute Program will see high risk members in the home in addition to providing post-acute oversight in identified skilled nursing facilities where needed. This is a hybrid position that focuses on advanced level interventions during transitional engagement points with an aim to improve outcomes and quality of care for a specific cohort of patients. This care is provided predominantly in the community where the NP will use his/her advanced practice skills to evaluate the older adult patient and provide medical management and counseling on disease processes unique to the geriatric/adult population.
This care is performed in conjunction with local area medical groups as well as in collaboration with care management teams and a nurse practitioner rounder. The NP in this role is responsible to build and foster these essential relationships with an aim to improve coordination of care as it relates to transitions of care and re-admission mitigation.
Key Responsibilities/Duties – what you will be doing
Transition of Care Visits
- Post hospital visits for high risk members in the community following an acute rehab stay or discharge from an acute facility in which additional support from an advanced clinician will reduce readmission risk and improve clinical outcomes
- Advanced clinical support for members defined as high risk based on multiple re-admissions, high disease burden, progressive disease presentations (COPD/CHF) or limited access to care within a defined geographical region
- Perform strong medication review and reconciliation with education to family and patient to improve understanding and compliance
- Engage and implement practices that improve continuity of care and secure primary care communication and follow up
- Enhanced level of care coordination with community providers and case management to assure strong clinical care plan as it relates to presenting condition with a focuses on collaboration and consistency
- Develop and ensuring a plan of care is in place, including anticipatory guidance and planning
- Facilitating access to appropriate support models of care i.e. hospice, rehabilitation
- Providing education and coaching to the member, family, and/or caregiver about health status, treatment options, disease trajectories and goals of care
- Demonstrate exceptional communication and collaborative skills with all care team members that will improve the care and outcome of the member and support ongoing medical, emotional, and functional needs
SNF Responsibilities
The NP in this role will at times be required to cross cover and co-manage patients in the post-acute setting. These patients will be identified as a specific member cohort and the nurse practitioner will collaborate with other rounders to primarily manage the patient during a skilled event and facilitate discharge planning back to the community.
Qualifications – what you need to perform the job
COVID Policy
Please note: All Direct Clinical Care Employees must be fully vaccinated against COVID-19, unless they obtain an exemption/accommodation pursuant to Point32Health’s process. As of August 31, 2023, all Direct Clinical Care Employees must be up to date on their COVID-19 vaccination, unless they obtain an exemption/accommodation pursuant to Point32Health’s process.
Compensation & Total Rewards Overview
As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
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Medical, dental and vision coverage
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Retirement plans
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Paid time off
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Employer-paid life and disability insurance with additional buy-up coverage options
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Tuition program
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Well-being benefits
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Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity
Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
