Advanced Practice Provider, Community Based

Job Summary

This role is community-based, focusing on providing both urgent and primary care to our members where they live. Working in partnership with the member’s primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.

Duties and Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges
• Work closely with the transitional care manager and the member’s primary care team, following through on the discharge plan with the member.
• Conduct patient/member assessments.
• Review, monitor, adjust and discontinue medications.
• Comprehensive Medication Review for adherence.
• Patient/Member and family education.
• Coordinate home care agencies and services.
• Develop and implement plan of care.
• Communicate patient’s medical, or mental conditions, substance abuse and social determinants of health needs.
• Document appropriately in the Electronic Medical Record.
• Gather critical information from member’s home environment and coordinates use of this information with healthcare team.
• Work collaboratively with the primary care provider, interdisciplinary office care team and transitional care manager,
• Support safe discharge transition and treatment in the community.
• Intervene with at-risk members to avoid unnecessary hospitalizations.
• Coordinate with care team, patient/member, family, and caregivers to help resolve barriers to care and transition back to Medical Center setting.
• Maintain the security and privacy of all information that is owned by or maintained on behalf of the company’s patients, employees, and business partners.

Qualifications:

• 2+ years as a Nurse Practitioner or Physician Assistant
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions
• Knowledge of local population, geography, and resources.
• Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Experience working with high risk and medically complex patients with multiple comorbidities preferred.
• Psychiatric and substance use disorder experience preferred.

Pay: From $150,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person