Proficiency with EMR systems, preferably eClinicalWorks
Strong organizational and communication skills
Knowledge of chronic disease management programs and managed care processes
Responsibilities
Manage health for a panel of 250-300 chronic care patients
Collaborate within a multidisciplinary team to implement care plans
Develop and track transitional care plans across various healthcare settings
Facilitate appropriate patient discharges from hospitals and skilled nursing facilities
Treat acute exacerbations of chronic conditions in an outpatient setting
Accept urgent appointments for patients needing intensified care
Educate patients on chronic disease management and healthy lifestyle choices
Benefits
Loan forgiveness up to $75,000
Full-time position with performance-based incentives
Opportunity to work in a supportive, integrated care team environment
Focus on whole-person care in an outpatient setting
Engagement in quality improvement initiatives through technology and EMR
Full Job Description
Job Summary
The Complex Care Advance Practice Provider duties include counseling patients regarding the most appropriate setting to meet their healthcare needs, performing assessments and evaluations of their problems, providing the appropriate information regarding specialist services, and end of life programs. Special attention is given to the PCMH model, evidence-based protocols and screening, and this role functions as a part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.
Duties and Responsibilities:
Manage and improve health for patients with multiple chronic medical conditions. Manage a panel of approximately 250 to 300 chronic care ambulatory patients in an office based.
Work in a team environment (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team. Work well with a supervising physician.
Develop strong transitional care plans and track paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care
Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) to facilitate appropriate discharge to a lower level of care or back to the AbsoluteCare Medical Center. Familiar with inpatient medicine and the discharge process to help facilitate discharges.
Treatment of some acute exacerbations of chronic conditions within the AbsoluteCare center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc.. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care needed. These treatments will involve collaboration and oversight with a supervising physician.
Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified practitioner or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
Track patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
Understands the PCMH model of care as pertains to specialist care, only utilizes this higher level of care as needed, and not a substitute for primary care using evidence based clinical skills
Educate patients regarding their chronic diseases, healthy choices, chronic disease progression and advanced directives.
Practice evidence-based medicine in accordance with the PCMH model of care.
Track and successfully achieve specified quality metric goals.
Use technology and the electronic medical record to the highest capability to increase quality initiatives and efficiency within the medical center.
Participate in multi-disciplinary meetings and recommend treatment alternatives designed to keep patients healthy or resolve on-going clinical issues.
Perform other duties as required consistent with chronic care and disease management services provided to patients.
Report to the Medical Director
Education and Experience requirements:
Licensed Advanced Practice Provider in the state of practice. Experience with patients who have multiple chronic medical conditions, i.e. CHF, COPD/Asthma, HTN, Diabetes, Chronic Renal Failure.
ACLS certification
Minimum of 2 years experience as a Advance Practice Provider mandatory
Experience with the management of Medicare, Medicaid, and commercial populations.
Knowledge of chronic disease management programs and services.
Excellent organization and communication skills
Comfortable with and the ability to treat the acutely ill in an outpatient setting offering IV hydration, IV antibiotics, wound care, and other services with the collaboration of a supervising physician.
Long-term interest in AbsoluteCare Medical Center
Proficiency with EMR, eClinicalWorks preferred
Knowledge of managed care and insurance processes is preferred
Highlights:
$150,000 - $165,000 Annual Salary Plus incentives (Full Time)Loan Forgiveness up to $75,000
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.
