Landmark Health Nurse Practitioner (Urgent Visits) in Hemet, California

Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

This role primarily provides medical care and management to members served by the Landmark program who request urgent visits to the NCM on call from 8:00 AM to 5:00 PM Monday – Friday (Non-Holiday). This position also participates in gathering clinical information for medical necessity determinations for service requests. Works with the Landmark Regional Medical Director, Director of Health Services, and IDT staff in the development and/or implementation of medical management policy, clinical protocols, utilization management guidelines, and quality management programs. Dedicated to improving the health and well-being of members, this position collaborates with the PCP, and as needed, the health plan Medical Director and other health professionals, to develop members’ goals of care in all phases of long-term care.

  • Practices in accordanve with the respective state laws and regulations governing the practive of advanced practice nursing or physician assistants.

  • Working with the NCM schedules patients for maintenance visits in a way and volume that allows prompt response to urgent patient requests during normal business hours.

  • Following the visit promptly communicates with the PCP and specialist as needed along with communicating findings to their primary assigned Landmark provider.

  • Completes the required documentation in a timely manner (goal <48 hours) allowing the care team a access to the care provided and a note to be generated to the PCP.

  • Understands and complies with long-term care policies and procedures, including those that regulate nursing facilities and assisted living communities.

  • Establishes and maintains effective relationships with members and their legal representatives, facility staff, PCPs and other collaborating physicians/providers.

  • Performs an initial comprehensive assessment on all newly enrolled members and at least bi-annually thereafter. Develops a member management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with members and/or their legal representatives to review newly developed or modified care plans; involves the PCP in these meetings.

  • Completes follow-up and post-hospital assessments according to documented standard operating procedure.

  • Prescribes appropriate diagnostics and interventions to avoid unnecessary transfers/acute admissions.

  • Consults with hospital physicians following notification of member transfer.

  • Collaborates with UM staff and PCPs/facility staff to enable medical necessity determinations for requested medical services.

  • Educates members and/or their legal representatives in disease processes affecting members and ways to manage them effectively, as well as to promote wellness.

  • Provides counsel, support and education to facility staff.

  • Supports FCMs in developing and providing in-service educational programs to facility staff.

  • Participates in management meetings that include, but may not be limited to:

  • Weekly case conference reviews

  • Monthly staff meetings

  • Schedule Joint Operating Committee meetings

  • Quarterly Quality Improvement Committee meetings

  • Continuing education/journal club programs

  • Implements HEDIS measure campaigns and other quality initiatives as directed by Corporate Health Services to ensure the highest standards of care and to promote the improvement of care management and delivery.

  • On-call for caseload during business hours. May require some participation in clinical on-call program as plan expands.

  • Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews.

  • Perform related duties as necessary and other duties as assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Completion of Nurse Practitioner accredited program

  • Minimum of two (2) years clinical experience, desired

  • Knowledge of long-term care, community resources and cost-effective alternatives regarding patient care delivery systems

  • Knowledge of CPT, ICD-9 and HCPC codes

  • Knowledge of clinical standards of care

  • Awareness about UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems is helpful

Job ID: 2016-1154

External Company URL: landmarkhealth.org