Job Purpose:

The Nurse Practitioner Supervisor - Centralized IDT will be an active member of the interdisciplinary team, playing an integral role in development an individualized plan for our participants and representing the primary care provider role in site level meetings. The Nurse Practitioner Supervisor - Centralized IDT is responsible for delivering high-quality, evidence-based clinical care and supporting population health initiatives through virtual and telehealth services. This role focuses on collaboration with interdisciplinary teams to develop, implement, and manage the medical care of our participants with involvement in clinical programs that improve patient outcomes, enhance care coordination, and support value-based care objectives. This role will have involvement in clinical programs, transitions of care, preventive care, Interdisciplinary Team support, and other strategic clinical initiatives while maintaining regulatory compliance and quality standards.

Job Responsibilities:

Interdisciplinary Team (IDT) Responsibilities

• Representation of the primary care provider at site level meetings including but not limited to: Morning report, Service Determination Request [SDR] review, Family meetings, and RCA meetings
• Representation of the primary care provider role in management of high risk/ high impact participants.
• Review of medical management of participants flagged as being high risk on the List of Participant Medical Records [LOPMR]
• Leads discussions with IDT related to authorization requests for specialist visits.
• Review of documentation from specialist providers. Presents information to IDT as appropriate.
• Only act within the scope of the individual’s authority to practice.
• Meet a standardized set of competencies for the specific position description established by TeamCare before working independently.

Clinical Care Delivery

• Conduct comprehensive patient assessments via telehealth platforms.
• Diagnose, treat, and manage acute and chronic health conditions within scope of practice.
• Prescribe medications and treatments as appropriate.
• Review laboratory, diagnostic, and imaging results and communicate findings to patients.
• Provide patient education and self-management support.
• Participate in IDT care plan meetings aligned with evidence-based guidelines.
• Support IDT Morning Report and SDR meetings in multiple sites.

Clinical Program Management

• Support development and implementation of clinical programs focused on population health.
• Participate in High risk high impact (HRHI), Transition of Care, Care Planning Meetings, Palliative Care Telemedicine.
• Collaborate/Lead assigned HRHI teams and implement targeted interventions.
• Participate in clinical programs operational meetings as necessary. Monitor program outcomes and recommend process improvements.
• Collaborate with leadership on program growth and operational efficiency.

Care Coordination

• Coordinate care with primary care providers, specialists, behavioral health clinicians, and community resources.
• Facilitate post-discharge follow-up and transitions of care.
• Participate in interdisciplinary case reviews and care conferences.
• Address gaps in care and quality measures.

Care Planning

• Work closely with the care planning team to ensure timely chart review and submission of care plan
• Provide medical insight into appropriate necessary medical action for the care plan
• Collaborate with internal and external providers as necessary to effectuate the care plan.

Quality and Compliance

• Ensure compliance with federal, state, and organizational policies.
• Maintain accurate and timely clinical documentation.
• Support quality improvement initiatives and performance metrics.
• Participate in audits, peer reviews, and accreditation activities.

Patient Engagement

• Promote patient adherence to treatment plans.
• Conduct outreach to patients requiring follow-up care.
• Utilize motivational interviewing and patient-centered communication techniques.
• Support patient satisfaction and experience initiatives.
• Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants; the care plan must be tailored to the needs of the individual, and all interventions and outcomes must be followed and supervised by the practitioner.
• Performs other duties as assigned.

Schedule:

Monday – Friday | 8:00AM – 12:00PM or 9:00am - 1:00pm

Weekly Hours: 20

Qualifications:

Education:

Graduated from an accredited Nurse Practitioner education program acceptable to NYSED or certified as a nurse practitioner by a national certifying organization acceptable to NYSED.

Experience:

Minimum of three (3) years of Nurse Practitioner experience strongly preferred. Experience in primary care, population health, care management, or value-based care preferred. Telehealth experience strongly preferred. Experience with clinical program development and implementation preferred. Minimum of one (1) year of experience working with adult population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the TeamCare organization. Effective oral and written communication and interpersonal skills required. High-level analytical and research skills. Ability to manage multiple projects and meet project deadlines. Basic Computer Skills in Microsoft office.

License:

Licensed to practice as a Nurse Practitioner in NY required. Licensed to practice as a Registered Nurse in NY required. DEA Certification required. AANP or ANCC Board Certification required. DEA registration (if applicable).

Additional Requirements:

Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function. Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. Must have a Medicaid Provider ID and a Medicare Provider ID in good standing. Strong clinical assessment and decision-making skills. Knowledge of value-based care and population health management. Familiarity with quality measures such as HEDIS, STAR, and CMS metrics. Excellent communication and patient engagement skills. Proficiency with Electronic Health Records (EHRs) and telehealth platforms. Strong organizational and project management abilities. Ability to work independently in a remote environment.

Language:

Bilingual preferred.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to: Standing – Duration of up to 6 hours a day. Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods. Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc. Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc. Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day. Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.) Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy. Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer:

Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.