Job description

We are looking for a full-time Nurse Practitioner or Physician Assistant who wants a get into the weeds, 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.

Role Responsibilities:

• 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

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 (a.k.a. grit), 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 innovate 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
• Has active DEA license
• HEDIS/STAR measures experience preferred