Nurse Care Advocate - Full-time / Part-time

Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

The Nurse Care Advocate (NCA) is responsible, as part of the care team, for the overall patient Care Management process. The NCA provides oversight, guidance and support for the patient care plan as developed through clinician, NCA and allied clinical support evaluation and physical risk assessment completed by a Landmark provider. 

The NCA uses telephonic nursing assessment and evaluation skills to help guide treatment and care decisions of the team and also identifies services and vendors for needed care while navigating patient benefit plans. The NCA works collaboratively with a multidisciplinary team of PCP, specialists, Behavioral Health clinicians, midlevel practitioners, pharmacist, nutritionist and social worker and the patient, family and/or caregiver as they provide supportive care to enrolled patients.

The NCA ensures that medical services are managed in the most effective and appropriate health care setting according to the patient’s medical condition. The NCA is responsible for developing and implementing a plan of care appropriate to the patient’s clinical condition and psycho/social needs to maximize his/her level of functioning and establishing and maintaining communications with the responsible party of the patient.

• Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication.
• This position is accountable for identifying and developing innovative actions to meet the needs of the patient from both the health care and psychosocial / socioeconomic dimensions of care as well as taking action for provision of services to meet those needs.
• The NCA utilizes nursing assessment skills and decision making authority to make recommendation and direct patient care to meet the needs of the patient and support the care recommendations of the multidisciplinary care team, the patient, family and caregiver.
• Complete an initial patient assessment on all new enrolled patients, including a medical record review where available
• Documentation of current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status
• Perform ongoing assessments commensurate with patient risk level and/or identified need
• Development of a plan of care to establish a collaborative approach to patient needs across clinicians and care delivery
• Initiate and maintain ongoing communications with clinicians involved in patient care, especially PCP
• Meet with families/responsible parties for collaboration on patient plan of care and discussion of patient/family/responsible party contribution to the ongoing management of patient condition as indicated
• Coordinate care across the continuum of care delivery model as the point of contact for patient/caregiver and clinicians
• Act as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the patient while promoting optimal clinical outcomes
• Monitor patient progress to plan of care goals with emphasis on patient care need during transitions and changes in patient level of care needs
• Monitor patient during admissions to both acute and skilled level of care to support patient needs, establish as the point of contact to clinicians and patient/responsible party/families to ensure consistent and ongoing communication between all involved parties
• Educate patients and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
• Reviews medical information collected including medical records and/or performs additional assessment to facilitate medical necessity determinations regarding service requests as established with in the identified program guidelines and the state established nurse scope of practice
• Serve as a resource to the entire care delivery team
• Identification and reporting of any quality of care issues including tracking and monitoring patient specific gaps in care
• Maintain HIPAA compliance as it relates to patient care

• Current LPN License
• 2-3 years of clinical practice in a hospital, clinic, home care, or nursing home setting
• 1-2 years of utilization management experience a must
• Case management experience desired
• Disease management experience useful
• Physician office experience helpful