Advance Practice Provider; Outpatient - Baltimore
Location: Baltimore, MD, USA
Highlights (Bonus, shift, relocation, info for job):
Monday - Friday; 8 am - 5 pm
The Complex Care Advance Practice Provider duties include counseling patients regarding the most appropriate setting to meet their healthcare needs, performing assessments and evaluations of their problems, providing the appropriate information regarding specialist services, and end of life programs. Special attention is given to the PCMH model, evidence-based protocols and screening, and this role functions as a part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.
Duties and Responsibilities:
- Manage and improve health for patients with multiple chronic medical conditions. Manage a panel of approximately 200 to 250 chronic care ambulatory patients in an office based.
- Work in a team environment (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team. Work well with a supervising physician.
- Develop strong transitional care plans and track paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care
- Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) to facilitate appropriate discharge to a lower level of care or back to the AbsoluteCare Medical Center. Familiar with inpatient medicine and the discharge process to help facilitate discharges.
- Treatment of some acute exacerbations of chronic conditions within the AbsoluteCare center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc.. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care needed. These treatments will involve collaboration and oversight with a supervising physician.
- Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified practitioner or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
- Track patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
- Understands the PCMH model of care as pertains to specialist care, only utilizes this higher level of care as needed, and not a substitute for primary care using evidence based clinical skills
- Educate patients regarding their chronic diseases, healthy choices, chronic disease progression and advanced directives.
- Practice evidence-based medicine in accordance with the PCMH model of care.
- Track and successfully achieve specified quality metric goals.
- Use technology and the electronic medical record to the highest capability to increase quality initiatives and efficiency within the medical center.
- Participate in multi-disciplinary meetings and recommend treatment alternatives designed to keep patients healthy or resolve on-going clinical issues.
- Perform other duties as required consistent with chronic care and disease management services provided to patients.
- Report to the Medical Director
Education and Experience requirements:
- Maryland Licensed Nurse Practitioner or Physician Assistant
- Experience with patients who have multiple chronic medical conditions, i.e. CHF, COPD/Asthma, HTN, Diabetes, Chronic Renal Failure.
- ACLS certification
- Experience with the management of Medicare, Medicaid, and commercial populations.
- Knowledge of chronic disease management programs and services.
- Excellent organization and communication skills
- Comfortable with and the ability to treat the acutely ill in an outpatient setting offering IV hydration, IV antibiotics, wound care, and other services with the collaboration of a supervising physician.
- Long-term interest in AbsoluteCare Medical Center
- Proficiency with EMR, eClinicalWorks preferred
- Knowledge of managed care and insurance processes is preferred
Why Work at AbsoluteCare?
At AbsoluteCare, 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.
AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.
EEO Employer Verbiage: AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.