Job Summary
This role is community-based, focusing on providing both urgent and primary care to our members where they live. Working in partnership with the members primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.
Duties and Responsibilities
Provide community-based medical and care-coordination services for recent hospital discharges
Work closely with the transitional care manager and the members primary care team,
Work collaboratively with the primary care provider, interdisciplinary office care team and transitional care manager,
Support safe discharge transition and treatment in the community.
Intervene with at-risk members to avoid unnecessary hospitalizations.
Coordinate with care team, patient/member, family, and caregivers to help resolve barriers to care and transition back to Medical Center setting.
Maintain the security and privacy of all information that is owned by AbsoluteCARE or maintained on behalf of the companys patients, employees, and business partners.
Nothing in this job description restricts managements right to assign or reassign duties and responsibilities to this job at any time. This description reflects managements assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned.
Qualifications:
Minimum of 2 years experience as a Nurse Practitioner or Physician Assistant
Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions
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.
Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
Patient-centered focus.
Psychiatric and substance use disorder experience preferred
Experience working with high risk and medically complex patients with multiple comorbidities preferred
Multiple settings experience (urgent care, ER, inpatient, office, or community based) preferred