Provides comprehensive primary care and clinical care coordination to a panel of patients
Facilitates and delivers preventative care to patients according to guidelines deemed appropriate by Clinical Leadership
Conduct Annual Visits with patients, taking a detailed history, performing a physical examination, and documenting appropriate diagnoses to develop a comprehensive medical care plan and ensure capture of high-risk diagnoses
Performs episodic urgent medical visits to ensure that patients are given timely and appropriate medical care
Prescribes medically necessary and appropriate medications and treatments
Performs post discharge visits on patients within two weeks of discharge from either an acute care facility or a skilled nursing facility
Collaborates with inpatient or post-acute care team and patient to optimize discharge planning
Documents all visits with focus on clear, comprehensive, and concise charting to identify, document, and execute a patient-centric plan of care

Master’s degree in Nursing or a degree in Physician Assistant Studies required
Doctoral degree of Nursing Practice preferred
Completion of accredited program and board certification as a Nurse Practitioner or Physician Assistant required
Two (2) years of experience as NP or PA caring for patients with complex medical, behavioral health, and social needs; preferred experience in community setting required or One (1) year of experience as NP or PA in primary care or care management and Three (3) years experience as Registered Nurse or EMT-P in a high touch clinical environment or home care required or Five (5) years experience as Registered Nurse or EMT-P in a high touch clinical environment or home care required
Experience with electronic medical record (eCW a plus) strongly preferred
Experience working with managed care population preferred
Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO) preferred

Care Delivery Advanced Practice Clinician

Key skills