Overview:

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.

Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region.

Brief summary of purpose:

Manages a primary care panel of participants and provides continuity primary health care to PACE participants that reside in the community or long-term care setting with a focus on goal oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant’s goals of care. Works in close collaboration with all members of the PACE Interdisciplinary Team.

Establishes realistic goals and helps develop and manage individualized plans of care with the IDT team for program participants.

Provides primary health care to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a participant-focused manner focusing on what matters most.

Works in close collaboration with the program’s interdisciplinary team to establish realistic goals and care plans and develop and manage individualized plans of care for program participants.

Responsibilities:

Primary Job Responsibilities (include duties that represent 5% or more of employee's time)

Performs post enrollment visits, biannual exams of participants and appropriately identifies and documents problems/issues in medical records
Evaluates episodic illnesses and issues appropriate diagnostic and therapeutic orders
Collaborates with physicians and other interdisciplinary team members to manage episodic and chronic medical needs of participants
Addresses and documents Advance Directives/MOLST discussion for participants a minimum of annually and when a change in participant condition occurs
Performs diagnostic, therapeutic and nursing intervention as indicated
Provides continuity in monitoring of chronic, stable illnesses
Implements the participant plan of care in a safe and effective manner
Participates in interdisciplinary team meetings
Evaluates effectiveness of previously implemented treatment
Conducts home and nursing home visits as indicated
Maintains accurate documentation and coding of all services provided according to professional standards
Identifies utilization and service delivery problems and participates in identifying a resolution
Identifies grievances and brings forward to leadership
Participates in quality assessment activities including but not limited to record reviews, outcome measurement and review/revision of policies and procedures
Provides education and training to participants, caregivers and staff in relevant topics
Acts a resource to program staff and participates in defining care standards and practices
Serves on appropriate committees, participates in all site and provider staff meetings including behavioral rounds and psychiatric rounds as indicated.
Enhances personal professional growth and self-development through participation in professional activities including educational programs, current literature, in-service programs, trainings and workshops.
Maintains BLS certification and professional certification as appropriate.
May be asked to perform other duties that align with Fallon Health’s mission, including but not limited to participation on clinical committees, providing education, quality initiatives and/or other activities.

Qualifications:

Education:

Master’s degree required. Graduate of an accredited Nurse Practioners program

License/Certifications:

Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing.
Driving your personal motor vehicle is an essential job function of this position and the following requirements apply:
- Must possess a valid drivers’ license
- Must attest to no disqualifiers per Driver Safety Policy
- Must possess and provide proof of minimal state required auto insurance
- Must have reliable transportation

Experience:

One to three years of Nurse Practitioner experience preferred with at least one year of experience in geriatric care.
Experience working in a healthcare setting as a member of a professional clinical team.
Experience with care coordination.
Other: Satisfactory Criminal Offender Record Information (CORI) results

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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Fallon Health

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