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Home Health Resource Group

Nurse Practitioner (NP) &ndash; Hybrid Care / MSO Model Health Connect MSOPOSITION SUMMARY T he Nurse Practitioner (NP) serves as a clinical decision-maker within the Health Connect MSO ecosystem, responsible for managing high-risk patients with chronic conditions through a hybrid care model that integrates:<ul><li>Remote Patient Monitoring (RPM)</li><li>Chronic Care Management (CCM)</li><li>Transitional Care Management (TCM)</li><li>Remote Therapeutic Monitoring (RTM)</li><li>Home-Based Primary Care (HBPC)</li></ul>The NP plays a critical role in preventing unnecessary 911 calls, ER visits, hospital admissions, and readmissions by providing timely clinical oversight and intervention based on real-time patient data and escalation from the monitoring team.CORE MISSION OF THE ROLETo stabilize patients in their place of residence, proactively manage chronic conditions, and ensure early clinical intervention before escalation to acute care settings.KEY RESPONSIBILITIES1. Clinical Oversight &amp; Decision-Making<ul><li>Review escalated patient cases from monitoring staff (MA team)</li><li>Evaluate abnormal vitals, symptoms, and trends from RPM data</li><li>Make timely clinical decisions to prevent deterioration</li><li>Adjust treatment plans, medications, and interventions as appropriate</li><li>Determine need for:</li><li>Home visit</li><li>Telehealth intervention</li><li>PCP/specialist escalation</li><li>Emergency care (if unavoidable)</li></ul>2. Remote Patient Monitoring (RPM) Management<ul><li>Interpret daily patient data:</li><li>Blood pressure</li><li>Glucose</li><li>Weight</li><li>Oxygen saturation</li><li>Identify early warning signs of:</li><li>CHF exacerbation</li><li>Hypertensive crisis</li><li>Hypo/hyperglycemia</li><li>Respiratory decline</li><li>Collaborate with monitoring team to ensure timely outreach</li></ul>3. Transitional Care Management (TCM)<ul><li>Conduct post-discharge follow-up within required timeframe</li><li>Ensure continuity of care from hospital/SNF to home</li><li>Reconcile medications</li><li>Prevent readmissions through early intervention</li></ul>4. Chronic Care Management (CCM)<ul><li>Develop and manage individualized care plans</li><li>Coordinate with PCPs and specialists</li><li>Address gaps in care and adherence</li><li>Support long-term stabilization of chronic conditions</li></ul>5. Home-Based Primary Care (HBPC)<ul><li>Conduct in-home or virtual visits for high-risk patients</li><li>Assess real-world patient conditions:</li><li>Medication management</li><li>Fall risks</li><li>Social determinants of health</li><li>Deliver patient-centered care in the home setting</li></ul>6. Collaboration with Monitoring Oversight Team<ul><li>Work in coordination with MA monitoring staff who:</li><li>Perform daily reminder calls</li><li>Conduct initial patient assessments</li><li>Provide clinical direction after escalation</li><li>Maintain clear separation between:</li><li>Monitoring functions (non-clinical)</li><li>Clinical decision-making (NP responsibility)</li></ul>7. Use of Health Connect One&trade; Platform<ul><li>Document all patient interactions within the system</li><li>Conduct audio/video consultations (time &amp; date stamped)</li><li>Review alerts and patient data dashboards</li><li>Ensure compliance with CMS documentation requirements</li></ul>8. Patient &amp; Family Education<ul><li>Reinforce chronic disease management strategies</li><li>Utilize Health Connect University&trade; resources</li><li>Improve patient adherence and engagement</li><li>Empower patients to recognize early warning signs</li></ul>CLINICAL FOCUS AREAS<ul><li>Congestive Heart Failure (CHF)</li><li>Hypertension</li><li>Diabetes</li><li>Chronic Kidney Disease (CKD)</li><li>COPD</li><li>Stroke recovery</li><li>Post-acute care patients</li></ul>PERFORMANCE METRICS (KPIs)The NP will be evaluated based on:<ul><li>Reduction in:</li><li>911 calls</li><li>ER visits</li><li>hospital admissions</li><li>hospital readmissions</li><li>Response time to escalations</li><li>Patient stabilization outcomes</li><li>Patient adherence and engagement</li><li>Documentation compliance (RPM/CCM/TCM)</li><li>Patient and caregiver satisfaction</li></ul>QUALIFICATIONS<ul><li>Licensed Nurse Practitioner (NP)</li><li>Active state license (multi-state preferred if applicable)</li><li>DEA license (if prescribing)</li><li>Experience in:</li><li>Primary care</li><li>Geriatrics</li><li>Chronic disease management</li><li>Home health or post-acute care (preferred)</li></ul>SKILLS &amp; COMPETENCIES<ul><li>Strong clinical decision-making ability</li><li>Experience with telehealth and remote monitoring</li><li>Ability to manage high-risk patient populations</li><li>Excellent communication with patients and care teams</li><li>Data-driven clinical thinking</li><li>Ability to work in a fast-paced, tech-enabled environment</li></ul>WORK MODEL<ul><li>Hybrid:</li><li>Remote (telehealth &amp; monitoring review)</li><li>Field (home visits as needed)</li><li>Flexible scheduling aligned with patient needs and escalations</li></ul>WHY THIS ROLE IS DIFFERENTThis is not a traditional NP role.You are:✔ Preventing emergencies&mdash;not reacting to them ✔ Managing patients before they decline ✔ Using real-time data to guide care ✔ Working inside a fully integrated care system ✔ Impacting outcomes at scaleIMPACT STATEMENT &ldquo;As a Nurse Practitioner at Health Connect MSO, you are the clinical leader responsible for keeping patients safe at home and out of the hospital through proactive, data-driven care.&rdquo;Pay: $68.00 - $85.00 per hourBenefits:<ul><li>Flexible schedule</li></ul>Work Location: Hybrid remote in Burlingame, CA 94010

Nurse Practitioner

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Nurse Practitioner