THE OPPORTUNITY:Medical Home Network is looking for a Geriatric Advanced Practice Provider to play a key role in delivering high-quality, patient-centered care to an ageing population. This person will help build, implement, and scale clinical programs focused on preventive care, wellness, care coordination, and age-friendly care models. The provider will deliver billable clinical services in collaboration with contracted health centers, including conducting Annual Wellness Visits (AWVs) and Advance Care Planning (ACP) discussions, while also contributing to program design, best practices, and continuous improvement.
This role offers a unique opportunity to advance preventive, geriatric-focused care for seniors in under-resourced communities. This position brings specialized geriatric expertise into community health centers that traditionally do not have dedicated geriatric services, enhancing both the level and quality of care delivered.
This role supports MHN's broader care delivery initiatives by guiding care management efforts across the organization and ensuring patients receive comprehensive, compassionate care. This role will work onsite at our partner health center locations in Springfield and Decatur, IL.
THE PERKS:- Fun, challenging, and collaborative work environment with passionate colleagues that care deeply about healthcare delivery.
- Recognized as One of the Best Places to Work in Healthcare by Modern Healthcare.
- Fitness reimbursement, commuter benefits, and tuition assistance.
- Great work life benefits- Paid time off, sick time, and 12 paid holidays.
- This role will work onsite at our partner health center locations across Springfield and Decatur, IL
- Onsite: Monday-Thursday
- Remote: Friday for administrative work
WHAT YOU CAN LOOK FORWARD TO:Clinical Care & Geriatric Focus- Provide comprehensive primary and preventive care services to aging patients enrolled in MHN's contracted health centers.
- Perform thorough assessments with a focus on chronic disease management, functional status, cognitive health, fall risk, and medication management.
- Develop individualized, patient-centered care plans in collaboration with patients, caregivers, and interdisciplinary teams.
Annual Wellness Visits (AWVs) - Conduct Medicare Annual Wellness Visits, including:
- Health risk assessments
- Cognitive and depression screenings
- Fall risk and functional assessments
- Medication reconciliation
- Preventive care planning and referrals
- Ensure accurate documentation and compliance with regulatory and payer requirements.
- Identify gaps in care and initiate appropriate follow-up or care coordination.
Advance Care Planning (ACP) - Lead compassionate, patient-centered Advance Care Planning discussions with patients and families.
- Assess patient goals, values, and preferences for future medical care.
- Facilitate completion and documentation of advance directives, POLST/MOLST forms, and related ACP documentation as appropriate.
- Collaborate with care teams to ensure ACP preferences are understood and honored across settings.
Program Development & Building - Contribute to the design, implementation, and scaling of clinical programs focused on geriatric care, preventive services, and population health.
- Help define workflows, clinical protocols, and quality standards for AWVs, ACP, and related initiatives.
- Partner with operations, clinical leadership, and quality teams to improve efficiency, outcomes, partner with operations, clinical leadership, and quality teams to improve efficiency, outcomes, and patient experience.
Collaboration & Quality - Work closely with physicians, nurses, care managers, social workers, and other interdisciplinary team members.
- Support quality improvement initiatives, documentation accuracy, and performance metrics related to value-based care.
- Educate patients, caregivers, and staff on preventive care, aging-related health topics, and care planning.
- Directly managing Medical Assistant(s)
WHAT YOU'LL NEED TO SUCCEED:Required - Active Nurse Practitioner license (IL)
- National NP certification (AANP or ANCC) or PA certification
- Experience in geriatric care required
- Demonstrated experience conducting AWVs and ACP discussions
- Strong communication skills and comfort with sensitive conversations
- Experience working in FQHCs or similar community health settings is strongly preferred.
- Prior experience building or scaling clinical programs
- Experience with primary care or population health
- Background in value-based care, risk adjustment, or quality initiatives
- Familiarity with EHR documentation and Medicare compliance
- Experience working with interdisciplinary or care management teams
- Fluent Spanish speaker is a plus
Required Education: - Master's degree or higher from an accredited Nurse Practitioner or Physician Assistant program
- Current, unrestricted Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of IL.
