**JOB PURPOSE:** In collaboration and consultation with physicians, staff RN's and other health care professionals, provides holistic, compassionate care to patients and families and provides care coordination and care management activities on behalf of the PruittHealth Premier Plan. Practices within the context of collaborative management with the physician(s) in diagnosing, managing, and preventing acute and chronic illness and disease, and promoting wellness. Nurse Practitioners have an advanced nursing practice that includes independent nursing functions based on nursing standards of care and a role in medical management working within a collaborative agreement with a physician(s). **KEY RESPONSIBILITIES:** 1. Proven ability to perform comprehensive, adult/geriatric physical exam 2. Demonstrates ability to identify, diagnose and document chronic disease in adults 3. Demonstrates ability to recognize conditions, characteristics, and behaviors that place seniors at risk 4. Proven ability to pursue feedback, continuing education and professional development 5. Ability to effectively reconcile medications 6. Demonstrates ability to identify and document the needs of clinically complex patients 7. Work collaboratively with physicians, case managers, social workers, family members, key care givers and any appropriate ancillary medical personnel as appropriate 8. Participates in and/or directs _Quality Assurance Performance Improvement_ (QAPI) activities 9. Understands the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decision-makers 10. Assesses the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team members 11. Coordinates care as member's transition through different levels of care and care settings, ensures that the ICP is communicated immediately and/or no later than 24 hours to the receiving care setting 12. Establishes schedule according to approved PHP nurse practitioner workflow 13. Establishes and documents visit schedule according the HRA stratification (low, moderate, high) 14. Ensures all Members have an ICP developed within 48 hours of HRAT 15. Facilitates agreement and implementation of the member's plan of care by engaging beneficiary, the facility staff, families/responsible parties, primary and specialty care physicians 16. Evaluates the effectiveness, necessity and efficiency of the plan, making revisions as needed 17. Utilizes practice guidelines and protocols established by PruittHealth Premier Plan **MINIMUM EDUCATION REQUIRED:** Graduate of an accredited Adult or Family Nurse Practitioner Master’s Degree program. **MINIMUM EXPERIENCE REQUIRED:** Minimum 2 years clinical experience as a Nurse Practitioner in geriatric, adult or family practice setting. Proven ability to perform comprehensive, adult/geriatric physical exam. **MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:** Current and unrestricted, RN and NP licensure in state of practice. Board certification by AANP or ANCC, in Adult, Family Practice and Geriatrics or Adult-Gerontology Primary Care. Current CPR certification **ADDITIONAL QUALIFICATIONS: (Preferred qualifications)** Graduate of an accredited Geriatric, Adult or Family Nurse Practitioner Master’s Degree program. Previous long term care experience strongly preferred. **KNOWLEDGE, SKILLS, ABILITIES** 1. Pertinent Clinical Work Experience which is relevant to population being served. 2. Reviews and interprets the medical and social history of members 3. Interprets laboratory data, recommend appropriate follow-up, reconcile medications 4. Manages both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider 5. Synthesizes information and easily diagnoses and creates a comprehensive plan of care. 6. Ensures that individual plan of care is developed with specific interventions designed to meet the needs identified in the Health Risk Assessment 7. Performs comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations 8. Performs Health Risk Assessment within seven (7) days of enrollment for a new beneficiary and annually within one year of the initial assessment. _9._ Conducts an annual Comprehensive Geriatric Exam that incorporates _CMS Annual a Wellness_ _Visit_ elements, including the Personalized Prevention Plan Services (PPPS) 10. Ensures all diagnoses are ICD-10 coded accurately and documented appropriately to support the diagnosis at that visit 11. Conducts HRA comprehensive face-to-face assessment if the member experiences a change in condition and/or transition in care—a “trigger” event. 12. Reviews orders and interventions for appropriateness and response to treatment to identify most effective plan of care that aligns with the member's needs and wishes 13. Evaluates plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations 14. May be required to participate in on-call program, after hour or coverage may be required 15. Rotating on call responsibilities 16. Travels between care sites mandatory 17. Performs other duties as assigned **Family Makes Us Stronger.** Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference. We are eager to connect with you! **_Apply Now_** to get started at PruittHealth! _As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status._