JOB SUMMARYThis role is integral to the organization's comprehensive care delivery system. The incumbent delivers high-quality, patient-centered care through in-home, virtual, and telephonic comprehensive clinical assessments for members with chronic health conditions. This autonomous position provides holistic, community-based care, especially for geriatric and palliative populations. The role proactively manages symptoms, guides advance care planning, and supports members with chronic or life-limiting illnesses to ensure optimal quality of life and health outcomes. The role involves accurately identifying and documenting all active chronic medical conditions essential for risk adjustment.
ESSENTIAL RESPONSIBILITIES- Comprehensive Clinical Assessments: Conduct comprehensive in-home, video, and telephonic clinical assessments, including detailed histories, physical examinations, and identification of all active diagnoses, symptoms, functional status, and social determinants of health.
- Diagnostic Interpretation & Treatment Planning: Order and interpret laboratory, radiological, and other diagnostic studies, then make medical diagnoses and institute appropriate therapy within applicable scope and standards of practice.
- Palliative Care & Symptom Management: Manage medications and treatments related to palliative care, alleviating pain and other distressing symptoms related to life-limiting illnesses.
- Patient & Family Guidance: Provide emotional and psychological support, and educate patients and families about illness progression, treatment options, and aligning to goals of care.
- Advance Care Planning: Facilitate advance care planning conversations and end-of-life discussions.
- Collaborative Care Coordination: Collaborate and coordinate care with other providers active on the patient's care team and participate in interdisciplinary team meetings to review and update patient care plans.
- Emergency Intervention: Institute emergency measures or appropriate stabilization for acute patient situations.
- EMR & Risk Adjustment Documentation: Utilize electronic medical record (EMR) systems for thorough and compliant clinical documentation, ensuring timely and accurate record of pertinent information to support comprehensive medical coding and risk adjustment methodologies.
- Reporting & Communication: Identify and inform the attending physician of record of all significant changes to the patient's ongoing condition in a timely manner.
- Professional Development & Compliance: Maintain mandatory professional continuing education and uphold professional practice consistent with organizational statements and medical staff compliance.
- Other duties as assigned or requested.
EDUCATIONRequired- Graduate from an accredited PA program OR Graduate from a Nursing Approved Master's or Post Master's program
SubstitutionsPreferred- Board certification or clinical experience in a relevant specialty (e.g., Family Medicine, Internal Medicine, Geriatrics, Hospice or Palliative Care).
EXPERIENCERequired- 3 years of clinical experience as an NP or PA, preferably in primary care, geriatrics, palliative or hospice care, chronic disease management, home health, or a similar community-based setting.
Preferred- Previous experience conducting in-home assessments or house calls.
- Knowledge of CMS regulations and guidelines.
- Experience in population health management.
LICENSES or CERTIFICATIONSRequired- Current Physician Assistant License OR Current State of PA RN licensure or Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) + CRNP license and Prescriptive Authority in the State of PA.
Preferred- DEA controlled substances license
SKILLS- Patient & Family Engagement: Exceptional communication, motivational interviewing and empathy skills for patient-centered care, sensitive health discussions, and effective education for diverse patient populations.
- Clinical Acumen & Care Planning: Expertise in critical clinical assessment and the ability to identify and address patient care gaps, opportunities for health improvement and formulate care plans including advance care planning.
- Interpersonal & Team Collaboration: Exceptional interpersonal and communication skills to build rapport and effectively collaborate with internal and external care teams.
- Autonomous Work & Caseload Management: Demonstrated ability to work autonomously and manage an effective caseload in a community-based or home care setting.
- Organizational & Time Management: Excellent organizational and time management skills to efficiently conduct multiple visits daily and complete documentation.
- Problem-Solving & Adaptability: Strong problem-solving skills and the ability to adapt to unexpected situations in the field.
- Technological Fluency: Proficient with EMR systems, portable diagnostic equipment, mobile technology, and standard computer applications including Microsoft Office products.
- Continuous Learning: Commitment to continuous learning and professional development, particularly in palliative care, geriatrics, risk adjustment, and clinical guidelines.
- Risk Adjustment & Documentation Acumen: Strong knowledge of risk adjustment methodologies and coding principles, coupled with the ability to ensure documentation integrity for compliant medical coding.
- High-Performing Team Integration: Ability to work effectively in a flexible, high-performing team environment.
Language (Other than English):None
Travel Requirement:50% - 75%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Rarely
Lifting: 25 to 50 pounds
Never
Exposure to Blood, body fluids or tissue
Occasionally
Exposure to needles or sharps
Occasionally
Additional Employment Requirements:- Valid driver's license and reliable transportation with appropriate insurance coverage to travel to patient homes across designated service areas.
- CPR Certification
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Pay Range Minimum:$102,700.00
Pay Range Maximum:$164,600.00
Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
