Home Care Nurse Practitioner - Inland Empire

Description

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Patient Care & Assessment:
  • Conduct comprehensive health assessments, physical examinations, and diagnostic evaluations for patients in their homes.
  • Complete transitions of care post-discharge.
  • Develop individualized care plans for high-risk patients, considering their medical history, comorbidities, and functional status.
  • Prescribe and manage medications, including managing complex drug regimens for chronic conditions such as heart failure, diabetes, COPD, and more.
  • Perform health screenings and provide preventive care to help minimize hospitalizations and emergency room visits.
• Palliative Care Management:
  • Assess patients for eligibility and appropriateness for palliative care, focusing on symptom management and quality of life for individuals with serious or life-limiting conditions.
  • Provide compassionate palliative care to improve comfort, alleviate pain, and address psychological, emotional, and spiritual needs for patients and their families.
  • Collaborate with the palliative care team to develop care plans that align with the patient's goals, preferences, and values.
  • Educate patients and families on palliative care options, including advanced care planning, pain and symptom management, and end-of-life care.
  • Monitor and adjust palliative interventions based on patient needs, ensuring a holistic approach to care that includes physical, emotional, and social well-being.
• Collaboration & Coordination:
  • Collaborate with interdisciplinary teams, including physicians, social workers, care coordinators, and family caregivers, to provide holistic patient care.
  • Ensure effective communication and care coordination between the home care team and any specialists involved in the patient’s care.
  • Serve as a primary point of contact for patients and their families, providing education, support, and guidance as needed.
• Chronic Disease Management:
  • Monitor and manage high-risk conditions in collaboration with the patient's care team, with a focus on chronic disease management and health promotion.
  • Educate patients and families on disease management, symptom control, medication adherence, and lifestyle modifications.
  • Review patient records regularly and update care plans to adjust to changing conditions or new diagnoses.
• Clinical Documentation & Reporting:
  • Accurately document all patient interactions, assessments, treatments, and progress in the Electronic Health Record (EHR) system.
  • Maintain confidentiality and comply with all relevant healthcare regulations and standards (e.g., HIPAA).
  • Participate in team rounds on patient progress, interventions, and outcomes.
• Patient Advocacy & Support:
  • Advocate for patients’ rights and ensure that they receive the best possible care and services in the home setting.
  • Address any concerns or challenges that arise in the home care environment, ensuring patient safety and satisfaction.
  • Support patients and families with end-of-life planning, palliative care needs, and grief counseling when appropriate.

Qualifications

• Current, unrestricted Nurse Practitioner license in CA and Furnishing License
• Fluent Spanish
• Certification as an Adult-Gerontology Nurse Practitioner (AGNP) or Family Nurse Practitioner (FNP), with additional certifications or experience in relevant specialties (e.g., palliative care, wound care, gerontology) preferred.
• Strong understanding of home health care protocols, chronic disease management, palliative care, and geriatric care.
• Ability and willingness to travel to patient homes.
• Ability to independently assess and manage patients in home settings with minimal supervision.
• Excellent communication and interpersonal skills, with the ability to work collaboratively in a multidisciplinary team.
• Ability to use electronic health records (EHR) systems and other clinical tools proficiently.
• Knowledge of state and federal regulations governing home care services.
• Strong critical thinking, problem-solving, and decision-making skills.
• Ability to work with patients from various cultural backgrounds, ability to utilize translational services.

• Minimum of 3-5 years of experience in a clinical nursing role, with a focus on high-risk, complex patients (home care and palliative care experience preferred).
• Experience in HEDIS and HCC

Environmental Job Requirements and Working Conditions

• This is a full-time, hybrid position, where you will be expected to travel to patient homes M-F 8 A - 5 P and also work from home.
• The patient visit schedule will be as follows:
  • M/Tu: Pomona
  • W: Riverside/Perris
  • Th: Palm Desert
  • Fri: San Bernardino
• The national total compensation target pay range for this role is between $140,000 - $170,000 annually. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.