Community Based Nurse Practitioner Job Summary

This role is a 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 NP is responsible for (1) seeing patients recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, (2) seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and (3) 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

• Working closely with the transitional care manager and the member’s primary care team, following through on the discharge plan with the patient.
• Conduct patient assessments
• Review, monitor, adjust and discontinue medications
• Comprehensive Medication Review for adherence
• Patient 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

Education & Experience Requirements

• Ohio licensed Nurse Practitioner with 2+ years’ experience
• Extensive knowledge of local population, geography, and resources.
• Excellent interpersonal and communications skills.
• 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
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions

 Preferred qualifications:

• 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.
• Psychiatric and substance use disorder experience helpful.