Sr Direct Care Practitioner - Boston, Bilingual preferred but not required

Who We ArePoint32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.Job SummaryUnder the direction of a Senior Products Manager, the Sr Direct Care Nurse Practitioner, as an advanced practice nurse (APN) in the Post-Acute and Long-Term Care Program, provides both primary and post-acute care and direct patient management to Senior Products members in designated facilities where we have established collaborative physician relationships. The SNF (skilled nursing facility) rounder will provide primary health care management to a long-term and custodial population with a focus on best practice approaches for the geriatric population as well as follow an identified subset of members who require post-acute management following an acute period of illness. The APN should be familiar with primary and preventative care approaches of the older adult with additional comfort in pharmacologic and end of life principles specific to this population. This oversight also includes annual wellness visits in facilities for eligible members.The APN will apply advanced practice skills to evaluate the older adult patient, provide medical management, and assess the patient’s progress toward identified goals to achieve the best possible clinical outcome along the health and illness continuum. This will be done in collaboration with all key stakeholders including collaborating physicians with whom the APN will build and support transparent and productive relationships.Job Description Key Responsibilities/Duties – what you will be doing (top five):POST ACUTE CAREPerforms comprehensive clinical exam and assessment upon admission Meets with facility staff and identifies the goal of the SNF stayFormulates discharge plan through discussion with multidisciplinary team with a focus on attainable goals and identified barriersAssess the patient at each visit to determine clinical status and progress towards goalsCollaborates and communicates with members of the care team to establish expected length of stay, goals of stay and level of care.Serves as a resource for fa...