Job Description

Job Description

Job Description

Why Work Here?

We serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer.

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works.

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT2.

The Community-Based Clinician provides needed primary care and urgent care in the home, with a strong 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 benefit from 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 issues in the home and clinic or by directing the member to the most effective and efficient solutions.

• Provide home visit clinical care to include:

  • 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 the 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 evidence-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:

• Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
• ACLS certified.
• Must be willing to do home visits.
• 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-Centered Medical Home.
• Experience working with high-risk and medically complex patients with multiple comorbidities.

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