Required skills & experience:

•You are a Board-Certified (or Board-Eligible within one year of employment) Nurse Practitioner or Physician’s Assistant with an unrestricted license to practice in the state in which you are seeking employment

•AANC or AANP certification for Nurse Practitioners

•Active DEA Controlled Substance Registration or eligible for application

•Certified in Basic Life Support for Healthcare Providers

•Maintenance of professional credentialing and CME standards

•Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.

•You have experience providing clinical services to individuals with both chronic medical and behavioral health conditions, and have interest in serving complex, vulnerable, and disabled populations

•70% of population treated will be pediatrics, so needs to have more FNP background familiar with treating children

•This model is Hub based, so not as much out in the field and more treating patients from Client Hubs.

What you need to know:

•You will work in a radically different model of healthcare

•Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners

•Co-manage a panel of members to improve their health holistically through longitudinal primary care, care management, and care coordination and be available via phone, during business at our hubs, or for member home-visiting

•Provide comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care.

•Perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization

•Conduct several home visits in a given day, including scheduled and unscheduled urgent member needs

•Perform post-discharge visits for your panel within 48 hours of discharge from either an acute care facility or skilled nursing facility to decrease risk of readmission; perform detailed medication reconciliation, and assure that appropriate long term services are in place