Programmatic support for our highest risk population.

At VillageMD, we are committed to helping patients achieve greater health by delivering the most effective, accessible, and efficient healthcare in the world through partnership with primary care physicians. Our high-risk program offers individualized, evidence-based, multidisciplinary, value-based care to our patients with the greatest needs in the care setting best suited to support their wellbeing including the PCP office, high risk clinics, patient homes, and other settings (e.g., dialysis centers). The high-risk team is dedicated to caring for complex, high-needs patients to improve their quality of life, enable them to live well and age healthfully at home and avoid hospitalizations. Each team member will play an essential role within the team.

What are the unique responsibilities of this position?

• Perform comprehensive in-home assessments for eligible patients post discharge with emphasis on medication reconciliation, patient understanding of discharge instructions, receipt of appropriate DME or home health referrals, and patient safety.

• Respond to urgent health concerns identified by the care team and optimally manage current symptoms and identified diagnoses to avoid utilization in the emergency room.Administer appropriate IV interventions including, but not limited to: fluids, antibiotics, or diuretics.

• Optimally manage current symptoms and identified diagnoses to avoid acute care utilization

• Complete physical examinations, medication reviews, vital checks, l wound care, depression screenings, and other applicable assessments.

• Complete advanced care planning to meet patient’s goals of care.

• Provide patient-caregiver self-management education and coaching to manage complex chronic medical conditions; emphasizing warning signs and what constitutes an emergent need in their specific circumstances.

• Assessment and management of pain.

• On-call coverage as required for patients under his/her care to include clinical triage of patients to appropriate care settings as required.

• Travel between hospitals, SNFs, clinics and patient’s homes to intercept patients post discharge.

• Engage with care team members in a timely manner to perform visits when discharged from an acute-care facility or setting

• Telephonic management of engaged patients for post discharge visits.

• Full oversight and knowledge of patient admissions and discharges, real time.

• Other duties as assigned by manager.

What profession and personal skills needed for success?

· A “yes” and “we” attitude to drive fruitful outcomes with internal and external partners, including patient.

• Ability to provide excellent care to patients in both a clinic setting and in the home, based on the needs of the business/market.

• Flexibility to accommodate a schedule that will change on a daily-basis and require travel to multiple care settings (Hospitals, home visits, in-clinic visits).

• Highly relationship oriented and ability to passionately serve the aging and elderly population.

• Ability to evaluate and treat complex chronic conditions in the office and home setting.

• Positive attitude with a solution-oriented approach and a comfort working within ambiguity.

• A low ego and humility; an ability to gain trust through communication and doing what you say you will do.

• Ability to receive constructive feedback from other team members, market Medical Director, and Management, and address opportunities for improvement.

• Ability to deliver constructive feedback to team members and discuss improvement opportunities.

• Open minded; willingness to try new ideas, consider different perspectives, and adapt to change.

• Ability to make decisions and create solutions that consider patient, team member, and business needs.

What will define success in this role?

Background and Educational Requirements

• Family Nurse Practitioner (FNP), Adult Nurse Practitioner with geriatric experience, Advance Practice Registered Nurse (APRN), or Physician Assistant (PA).

• Current Arizona License.

• Nurse Practitioner Certification from the ANCC or AANP.

• 3+ years of clinical experience as an APRN / FNP / PA in the primary care or home care setting.

• Working knowledge of chronic care management and various medication options.

• Current DEA license/Prescriptive Authority post-hire in state.

• Experience in Family Medicine, Internal Medicine, Geriatrics, Palliative Care, or home care.

Behavioral Competencies

• Self-motivated: energetic, self-starter; can work autonomously with limited direction.

• Results oriented: bias for action; demonstrated track record of achievement; drive for attainment of superior outcomes.

• Flexible: ably navigates within ambiguity; solution oriented.

• Communication: conveys thoughts and expresses ideas effectively both verbally and in writing; strong presentation skills.

• Collaboration: orientation to team-based work product and results.

• Service: Actively supports others, demonstrates an optimistic, can-do approach to issue resolution.

• Humility: low ego; engenders trust; respectful.

Physical Requirements

• Ability to lift and carry up to 50lbs

• Frequent sitting; Occasional standing & walking; Close eye work (computers, typing, reading, writing); Physical demands may vary depending on assigned work area and work tasks. ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include but are not limited to: Blood-borne pathogen exposure; Bio-hazardous waste Chemicals/gases/fumes/vapors; Communicable diseases; Electrical shock; Floor Surfaces; Hot/Cold Temperatures; Latex; Lighting; Patient care/handling injuries; Travel may be required; Use of personal protective equipment, including respirators.

How you will thrive

In addition to competitive salaries, a 401k program and a valuable health benefits package, VillageMD offers paid parental leave, pre-tax savings on commuter expenses, and generous paid time off. You work in a highly-collaborative, conscientious, forward-thinking environment that welcomes your experience and enables you to make a significant impact from Day 1.

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