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 member’s 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 member’s primary care team, following through on the discharge plan with the member.
  • Conduct patient/member assessments.
  • Review, monitor, adjust and discontinue medications.
  • Comprehensive Medication Review for adherence.
  • Patient/Member and family education.
  • Coordinate home care agencies and services.
  • Develop and implement plan of care.
  • Communicate patient’s medical, or mental conditions, substance abuse and social determinants of health needs.
  • Document appropriately in the Electronic Medical Record.
  • Gather critical information from member’s home environment and coordinates use of this information with healthcare 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 company’s patients, employees, and business partners.
• Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned.

Qualifications:

• Nurse Practitioner/Physician Assistant with 2 or more years’ experience. 
• Multiple settings experience (urgent care, ER, inpatient, office, or community based) preferred.
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions
• Experience working with high risk and medically complex patients with multiple comorbidities preferred.
• Psychiatric and substance use disorder experience helpful.
• Extensive knowledge of local population, geography, and resources.
• 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.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.

Working conditions:

This job operates in a patient care setting where there is potential exposure to blood, bodily fluids, and infectious materials. This role routinely uses general office equipment. Often wear a special uniform, such as a lab coat or surgical scrubs, protective or safety attire, such as gloves and masks. High patient traffic, close quartered and shared workspace. Physical requirements

• Job may be physically demanding at times.
• Remain stationary for long periods of time.
• Repetitious movements.
• Frequently move equipment or supplies weighing up to 20 lbs.

Direct reports:

None

All Employees are expected to maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.