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This role is community-based, focusing on providing both urgent and primary care to their members where they live. Working in partnership with the member’s primary care provider and interdisciplinary team, the community-based NP is responsible for (1) seeing patients recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, (2) seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and (3) 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
Working closely with the transitional care manager and the member’s primary care team, following through on the discharge plan with the patient.
Conduct patient assessments
Review, monitor, adjust and discontinue medications
Comprehensive Medication Review for adherence
Patient 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, family and caregivers to help resolve barriers to care an transition back to Medical Center setting.
Education & Experience Requirements
Nurse Practitioner or Physician Assistant with 2+ years’ experience
Extensive knowledge of local population, geography, and resources.
Excellent interpersonal and communications skills.
Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
Ability to meet deadlines and manage multiple priorities.
Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
Excellent computer skills, including knowledge of Microsoft Office.
Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions
Experience working with high risk and medically complex patients with multiple comorbidities preferred.
Multiple settings experience (urgent care, ER, inpatient, office, or community based) preferred.
Psychiatric and substance use disorder experience helpful.
Our employees are offered the following benefits
Free Vision Plan
Medical and Dental plans
Short Term Disability
401k Retirement plan
Providers eligible for 10% annual bonus
Please email CV to [Register to View]
O Fallon, Missouri, United States
Jordan Search Consultants is a St. Louis-based healthcare, executive, and higher education search firm serving clients nationwide. Our executive search specialists and healthcare recruitment experts have almost a century of combined experience in the industry. We partner with client organizations throughout the U.S. to provide the best recruitment services to both clients and candidates by buildin...