Are you a compassionate mission-driven Nurse Practitioner looking to make a meaningful impact on the lives of complex medical patients? As a Nurse Practitioner at GGH, you'll bring hope and healing to patients with complex medical needs. In this full time role, you'll be a vital member of an interdisciplinary team, transforming lives and empowering primary care physicians to deliver exceptional care to those who need it most.

This role requires a multifaceted approach, encompassing all aspects of care delivery. Comprehensive geriatric assessments may be conducted in-office, via telemedicine, or through on-site visits at senior facilities, patient homes, dialysis centers, and other appropriate locations. Close collaboration with primary care physicians is a must to avoid fragmented care.

The scope of practice includes managing quality measures, performing accurate risk assessments, recommending adjustments to longitudinal care, providing care for non-life or limb threatening urgent concerns, facilitating advanced care planning, and other key actions while collaborating with an interdisciplinary team to align care with patient health goals. The above actions, combined with preventive and timely patient care, afford emergency department and hospital admission avoidance which is a known factor in decreasing complications while maintaining a higher quality of life in this subset of patients.

What will you do as a High Risk Nurse Practitioner at GGH?

• Conduct comprehensive health assessments for members in a variety of settings.
• Perform transition of care visits to ensure patient understanding of discharge instructions, remove barriers for recovery and reduce avoidable hospital readmissions or emergency department visits.
• Perform comprehensive geriatric assessments using sound clinical judgment.
• Identify care gaps and communicate recommended interventions to the member’s primary care provider and care team.
• Triage and manage non-life or limb threatening conditions.
• Collaborate with interdisciplinary teams using data-driven clinical tools to support coordinated, value-based care.
• Collaborate with the Regional Clinical Medical Director or designee when assistance in clinical decision making is identified.
• Communicate opportunities to advance the clinical model.
• Educate P3 team members when necessary.
• Educate patients, their families and caretakers on health maintenance, chronic disease management, medications, and preventive care.
• Confidently use technology and evidence-based medicine to guide care planning and decision-making.
• Ensure patient privacy and adherence to all HIPAA regulations and standards for handling PHI.
• Participate in quality improvement initiatives, documentation audits, and other activities that support clinical excellence and operational efficiency.
• Maintain compliance with required trainings, timely chart closures, chart queries, meeting attendance and other requirements.
• Serve as a positive and collaborative leader and team member.
• Maintain a license and DEA certificate in good standing.
• Role model GGH core values.