JOB PURPOSE: The Nurse Practitioner Supervisor - Centralized IDT will be an active member of the interdisciplinary team, playing an integral role in development an individualized plan for our participants and representing the primary care provider role in site level meetings. The Nurse Practitioner Supervisor - Centralized IDT is responsible for delivering high-quality, evidence-based clinical care and supporting population health initiatives through virtual and telehealth services. This role focuses on collaboration with interdisciplinary teams to develop, implement, and manage the medical care of our participants with involvement in clinical programs that improve patient outcomes, enhance care coordination, and support value-based care objectives. This role will have involvement in clinical programs, transitions of care, preventive care, Interdisciplinary Team support, and other strategic clinical initiatives while maintaining regulatory compliance and quality standards. JOB RESPONSIBILITIES: Interdisciplinary Team (IDT) Responsibilities Representation of the primary care provider at site level meetings including but not limited to: • Morning report, Service Determination Request [SDR] review, Family meetings, and RCA meetings • Representation of the primary care provider role in management of high risk/ high impact participants. • Review of medical management of participants flagged as being high risk on the List of Participant Medical Records [LOPMR] • Leads discussions with IDT related to authorization requests for specialist visits. • Review of documentation from specialist providers. Presents information to IDT as appropriate. • Only act within the scope of the individual’s authority to practice. • Meet a standardized set of competencies for the specific position description established by TeamCare before working independently. Clinical Care Delivery • Conduct comprehensive patient assessments via telehealth platforms. • Diagnose, treat, and manage acute and chronic health conditions within scope of practice. • Prescribe medications and treatments as appropriate. • Review laboratory, diagnostic, and imaging results and communicate findings to patients. • Provide patient education and self-management support. • Participate in IDT care plan meetings aligned with evidence-based guidelines. • Support IDT Morning Report and SDR meetings in multiple sites. Clinical Program Management • Support development and implementation of clinical programs focused on population health. • Participate in High risk high impact (HRHI), Transition of Care, Care Planning Meetings, Palliative Care Telemedicine. • Collaborate/Lead assigned HRHI teams and implement targeted interventions. • Participate in clinical programs operational meetings as necessary. Monitor program outcomes and recommend process improvements. • Collaborate with leadership on program growth and operational efficiency. Care Coordination • Coordinate care with primary care providers, specialists, behavioral health clinicians, and community resources. • Facilitate post-discharge follow-up and transitions of care. • Participate in interdisciplinary case reviews and care conferences. • Address gaps in care and quality measures. Care Planning • Work closely with the care planning team to ensure timely chart review and submission of care plan • Provide medical insight into appropriate necessary medical action for the care plan • Collaborate with internal and external providers as necessary to effectuate the care plan. Quality and Compliance • Ensure compliance with federal, state, and organizational policies. • Maintain accurate and timely clinical documentation. • Support quality improvement initiatives and performance metrics. • Participate in audits, peer reviews, and accreditation activities. Patient Engagement • Promote patient adherence to treatment plans. • Conduct outreach to patients requiring follow-up care. • Utilize motivational interviewing and patient-centered communication techniques. • Support patient satisfaction and experience initiatives. • Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants; the care plan must be tailored to the needs of the individual, and all interventions and outcomes must be followed and supervised by the practitioner. • Performs other duties as assigned. Schedule: Monday – Friday | 8:00AM – 12:00PM or 9:00am - 1:00pm Weekly Hours: 20 Location: Remote
