Job Description:
PURPOSE OF JOB

To provide comprehensive, person-centered, longitudinal community based preventive care and care

management (CM) interventions for participants and families. Effectively engage, assess, monitor, educate

and provide interventions for participants and families to improve the quality of care, participant health

outcomes, and reduce unnecessary health care utilization. Collaborate with physicians, hospitals, skilled

nursing facilities, home health providers and community services to advocate for patient needs, to promote

better health, and to prevent unnecessary hospital utilization.

II. ESSENTIAL FUNCTIONS

1. Independently completes comprehensive advanced level nursing assessments that include focused

physical examinations with attention to common geriatric syndromes. Practice incorporates a

sophisticated knowledge of evidence-based, best practice standards of care for chronically ill older

adults. Uses clinical knowledge and sound judgment to identify subtle changes in participants'

status, and anticipates and intervenes to prevent problems and complications.

2. Effectively engages, assesses and provides interventions and support for participants, their families and

caregivers to address medical, health, social, psychological, environmental and lifestyle issues; with

the goal of improving health and preventing unnecessary hospital utilization. Interventions are

delivered through one on one inperson contact with participants and families in their home, in

physician offices, in groups, and through follow-up monitoring by telephone.

3. Collaborates with physicians, hospitals, skilled nursing facilities, home health care providers and

community service agencies to coordinate and improve the care for participants. Effectively

communicates with healthcare providers and advocates for participants from an individualized

person-centered perspective.

4. Demonstrates extraordinary teamwork to meet the dynamic needs of the participants and of the team

and program, in a fast paced, dynamic and learning environment. Incorporates HQP's program

principles into practice (person centered; a robust set of population relevant interventions; reliable;

anticipatory and accountable).

Job Qualifications:
QUALIFICATIONS & REQUIREMENTS

Education: RN with Bachelors or Masters of Science in Nursing preferred

Experience: Minimum five years of current clinical experience, ideally in one or more of the following areas or

specialty practice: medical-surgical, home care, hospice, community health, rehabilitation, long term care,

cardiovascular, diabetes, and or pulmonary diseases, oncology and geriatrics.

Other Knowledge and Skills:

? Current clinical knowledge in geriatrics, chronic diseases, heart failure, heart disease, COPD, diabetes and other co-morbidities.

? Proficiency with electronic documentation keyboarding

? Demonstrated ability to function independently with sound clinical and professional judgment

? Must be a self-initiator with high energy/productivity and a strong work ethic

? Proven history as a team player

? Flexibility and adaptability in managing multiple priorities, changing schedule

? Excellent communication skills (written and verbal)

? Excellent organizational and time management skills

Additional Requirements:

PA and NJ (or eligible) RN license

Basic Life Support (BLS) certification

Must have own vehicle for daily travel throughout the HQP service region

Must maintain and provide proo f of a valid driver's license

Must have, maintain and provide proof of automobile insurance coverage as required by law