Certified Registered Advance Practice Provider in Adult Medicine with Acute Care experience
ACLS certified
Strong problem-solving skills to help patients overcome care barriers
Ability to manage multiple priorities and meet deadlines
Experience with Electronic Medical Records and data analysis
Excellent computer skills, including Microsoft Office proficiency
Patient-centered focus with knowledge of care transitions and chronic condition management
Responsibilities
Provide community-based medical and care-coordination services for recent hospital discharges
Manage a small panel of homebound members requiring primary care
Resolve acute issues in the home or clinic, directing members to effective solutions
Ensure timely and accurate completion of chart documents
Collaborate with Integrated Care Team members for problem-solving and care coordination
Identify and refer patients to specialty programs during crises
Educate patients on medication adherence and chronic disease self-management
Benefits
Up to $75,000 in loan forgiveness
Opportunities for professional growth and development
Supportive team environment focused on patient care
Access to resources for managing complex patient needs
Flexible work environment with home visit opportunities
Full Job Description
The Community-based Clinician provides needed primary and urgent care in the home. Great focus on managing transitions of care, especially in the important and delicate time after hospital discharge. This position adds to a member's current care, collaborating with their current care providers. The role is immensely satisfying, as you practice enhanced primary care and have the benefit of expert care management. Seeing members in the home allows you great insight into the social factors that affect their care. This is a tremendous opportunity to impact the care of vulnerable patients.
Duties and Responsibilities
Provide community-based medical and care-coordination services for recent hospital discharges. Manage a small panel of homebound members who require primary care. Resolve acute issue in the home and clinic or by directing member to most effective and efficient solutions.
Acute onset of a new illness.
Evaluation of acute exacerbations of chronic conditions.
Shortness of breath without chest pain, change in mental status or new onset hypoxia.
CHF exacerbations
Asthma/COPD exacerbations
Bronchitis/pneumonia
Hyperglycemia
Elevated blood pressure
Evaluation and treatment of a variety of infections
New or worsening aches or pains, wounds, depression and/or anxiety.
Members we know will go to the ER if not seen today.
Ensure coordination of care to include:
Timely and accurate completion of chart documents.
Work with Treatment and Triage Nurse to address sick calls and visits requiring Provider management.
Receive input from the Core Clinical Team (PCP, Care Manager or SW) to define visit goals.
Communicate important post visit follow up information to Core Clinical Team.
Collaborate with Integrated Care Team (ICT) members (behavioral health, nutrition, health education) for problem solving and coordination of care.
Identify and refer to specialty programs when instability or crisis occurs such as: abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
Implement transitional care protocols as part of warm hand offs between internal and external care providers.
Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
Adjust care plan following guidelines for evidenced based chronic disease management.
Educate and coach for medication adherence and chronic disease self-management skill development.
Monitor members at risk of being lost to care and implement interventions to prevent loss.
Education & Experience Requirements:
This is a Community Based position must be willing to do home visits
Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
ACLS certified.
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.
Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
Excellent computer skills, including knowledge of Microsoft Office.
Patient-centered focus.
Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions.
Preferred qualifications:
Experience in a Patient Center Medical Home.
Experience working with high risk and medically complex patients with multiple comorbidities.
Highlights:
Up to $75,000 in Loan ForgivenessSalary Range $150,000 - $165,000 per year plus incentives
About AbsoluteCARE
AbsoluteCARE is a healthcare provider that offers comprehensive primary care services, as well as specialized care for individuals with complex medical needs. The company's approach is centered around a patient-centered medical home model, which emphasizes coordinated care and a focus on prevention and wellness. AbsoluteCARE's services include chronic disease management, behavioral health, and medication management, among others. The company operates several clinics in the southeastern United States, and has partnerships with a number of health plans and providers.
