Nurse Practitioner (PC)

Company: NYC Health + Hospitals
Location: New York
Posted on: March 14, 2025

Job Description:

Marketing StatementSince 1875, South Brooklyn Health has established its reputation for clinical excellence and culturally competent care. It has designations as a Certified Percutaneous Coronary Intervention (PCI) Center, an Advanced Primary Stroke Center, an accredited Baby-Friendly Hospital, a U.S. News & World Report high performing hospital. The hospital's staff is as diverse as the patients they serve. Interpreter services can be provided at any time of the day or night in over 130 languages.At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.PurposeJob DescriptionPlan, organize, direct, coordinate and evaluate chronic care services and support chronic illness care improvement activities based chronic disease collaborative initiatives in Primary Care and Ida G Israel. Work with the facility and collaborative teams to continue improvement of care delivery for those with chronic illnesses. Promote interdisciplinary collaboration, foster team work and champion chronic care excellence. Participate in the outreach, evaluation, assessment, education and triage of patients in collaboration with Attending Physicians participating in the care of patients with chronic diseases like Diabetes and Hypertension.Specific Duties And ResponsibilitiesThe Chronic Disease Coordinator is charged with and responsible for:

• Work at our adult primary care clinics to improve the quality of chronic disease care
• Focus 70% of time on direct patient care and 30% on performance improvement responsibilities
• Provide direct clinical care, for patients with uncontrolled chronic conditions e.g., hypertension, diabetes, high cholesterol, Asthma, Arthritis, Cancer Screens, and Smoking Cessation. This can include
• Educate patients about diagnosis, treatment, medications, and needed follow-up
• Conduct follow-up visits for HTN management, diabetes medication titration, high cholesterol, Asthma, Arthritis, Cancer Screens, and Smoking Cessation, teaching on use of devices like continuous blood glucose monitors
• Navigate patients through care management, required primary, secondary, tertiary care, and assist with access to all required lab, imaging, and path services, etc
• Outreach patients not engaged with care, order appropriate labs and medications as needed
• Identify underlying challenges i.e. socioeconomic, cultural, physical or language barriers
• Collaborate with patients, families and care team to address barriers, using strategies such as motivational interviewing and brief action planning
• Liaise with social work department or Community Health Workers to develop strategies to address social determinants of health (e.g., homelessness or food insecurity)
• Organize group medical visits and moderate discussion to optimize peer-peer support
• Document care rendered in EMR and bill for services provided
• Participate in performance improvement initiatives including Quality Academy
• Present chronic disease data at the Ambulatory Care Quality meeting. Broadcast plans via SBH Administrator, share performance, best practices and updates at Amb Care Meetings
• Manage Care/VBP gaps ensuring adequate documentation, coding, referral & order coordination for imaging, DM Education, collaboration with clinical pharmacists for medication management, dietary and weight management. Collaborate with VBP coach and Primary Care leadership to improve care gaps.
• Implement patient education materials, campaigns and forums for chronic disease prevention, preventative services, etc.
• Collaborate with central office staff in the Office of Population Health to implement chronic disease performance improvement initiatives.
• Report progress bi-weekly on facility chronic disease initiatives
• Coordinate and collaborate with facility clinical, nursing and administrative leadership to drive continuous performance improvement for chronic disease management
• Educate ambulatory nursing staff on chronic disease initiatives
• Monitor adherence of ambulatory nursing staff to performance improvement plans
• Track and share quality metrics with stakeholders across the facility
• Implement OPH disease management toolkits to drive facility change
• Coordinate with OPH and facility leadership to address barriers in achieving improvement goals
• Other duties as assignedMinimum Qualifications
  • A valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Department of Education (NYSED); and
  • Current certificate as a Nurse Practitioner issued by the NYSED; and
  • Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).Department PreferencesStrongly prefer National Board Certification in specialty in which you are assigned.
    • Strong computer skills: Microsoft Word, Excel and Power Point
    • Epic proficiency preferred
    • Good Organizational And Time Management Skills Required
    • Complete the CDCES or BC-ADM credential within one year of employment, if possible.How To ApplyIf you wish to apply for this position, please apply online by clicking the "Apply Now" button.NYC Health and Hospitals offers a competitive benefits package that includes:
      • Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
      • Retirement Savings and Pension Plans
      • Loan Forgiveness Programs for eligible employees
      • Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
      • College tuition discounts and professional development opportunities
      • Multiple employee discounts programs

Keywords: NYC Health + Hospitals, New York , Nurse Practitioner (PC), Healthcare , New York, New York