Reporting to the Clinical Service Manager, the Advanced Practice Provider (Nurse Practitioner, Physician Assistant) will be based in the indicated market. This provider will work to identify, implement, and improve care solutions to achieve the Quadruple Aim in health care delivery in their local market.

This is a build-it and make it better kind of job, requiring high energy, deep engagement and a strong work ethic. This individual understands the necessity of offering differentiated treatment models for vulnerable populations across a broad chronic illness spectrum and will be able to effectively build will and implement innovative care solutions.

  • Delivers cost-effective, high-quality care to assigned patients
  • Completes comprehensive history and head to toe physical examination on all enrolled patients in an in-home visit
  • Collaborates with Care Team and patient to determine patient’s risk of adverse health outcomes
  • Adjusts the patient’s risk level as appropriate based on assessments
  • Completes proactive, in-home visits on patients as determines by risk level
  • Completes post hospital discharge, unplanned, urgent, and/or emergent in-home visits as needed to meet patient needs
  • Adjusts visit frequency and schedule based upon patient needs
  • Responds to calls from the patient, caregiver, Care Team
  • Addresses Advance Care Planning, Patient Goals and Prognosis every 6 months and with every acute change in condition; identifies surrogate decision maker (MPOA, Health Proxy, etc.)
  • Manages patient’s medical care as appropriate including:
    • Orders and monitors of diagnostics including laboratory studies, radiological studies, etc.
    • Refers to appropriate specialists or community services, i.e. Home Health, DME, community resources
    • Addresses recommended preventive and quality measures; acts to close potential care gaps
    • Monitors chronic conditions to minimize exacerbations or treat (in place if clinically appropriate)
    • Identifies, assesses, diagnoses, treats acute changes of condition (in place if clinically appropriate)
    • Manages medication therapy effectively:
      • Reviews and reconciles medications each visit
      • Avoids high-risk medications
      • Prescribes medication, adjusts dosages, discontinues medications as appropriate
      • Simplifies medication regimen for improved adherence to 
    • Administers selected medications in the home (if clinically safe to do so)
  • Collaborates with Care Team in the development of an integrated care plan that identifies key patient problems, goals of care, barriers to meeting goals, interventions, activation level, and patient self-management activities
  • Communicates effectively with entire care team including the patient’s community primary care provider
  • Provides effective patient education using the Teach Back technique
  • Documents all patient encounters (in-home and telephonic) per documentation standards
  • Participates in clinical case conferences as required
  • Participates in Multidisciplinary Team Meetings
  • Participates in on-call coverage for patient care
  • Communication Skills, knowledge of Motivational Interviewing
    • Must have a strong desire to build close relationships with all members of the field and regional teams.
    • Must be committed to working in a collaborative relationship with the members primary care provider.
    • Excellent time management, organizational skills, and strong communication is a must.

Role Qualifications:
We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion and perseverance to achieve long-term goals, team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery system.

Flexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovative health care delivery solutions. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. 
Additional qualifications include:

  • Graduate of an accredited health professional school
  • Board Certified AANP, AANC, PA
  • Certification and/or training in Emergency Medicine, Gerontology, or Palliative Care is preferred
  • At least two years of clinical experience delivering care to complex patients preferred, including in the home and skilled nursing facility settings
  • Strong knowledge of best clinical practices as they relate to population health 
  • Strong knowledge of best clinical practices, particularly in the urgent and post-acute care settings
  • Must be skilled in delivering care across medical, behavioral, and social needs, particularly for patients living with mental illness and substance use disorders
  • Demonstrated ability to collaborate both internally and externally with multi-disciplinary care team members
  • Active license in the indicated State, or ability to obtain one within 90 days
  • Current Certification in AHA or ARC Basic Life Support for health care providers preferred (if not, expectation will be to become certified within first 120 days)
  • Working knowledge of computers and ability to document effectively and efficiently in an electronic medical record system
  • Driver’s license requirements: licensed for a minimum of 3 years without restrictions; no
  • DUI or other felony driving conviction in the past 7 years
  • Active DEA license
  • HEDIS/STAR measures experience preferred