Care Delivery Advanced Practice Clinician - Hybrid (Springfield Office / Mobile)

Job Summary:

The Care Delivery Advanced Practice Clinician (APC) provides comprehensive primary care and clinical care coordination to a panel of patients, including individuals with significant medical, behavioral, and social complexities that require intensive care coordination and care delivery.  This role provides ongoing chronic disease consultation and management, promotes preventative care through education and identification of age-appropriate preventative screens, provides urgent care, and acts as a liaison with other health professionals as needed.

Essential Functions

• Performs longitudinal primary care and wrap-around care including routine, and urgent care for an attributed patient panel in clinic, through home visits, and utilizing telehealth technologies (video, chat, etc.).
• Facilitates and delivers preventative care to patients according to guidelines deemed appropriate by Clinical Leadership.
• Conduct Annual Visits with patients, taking a detailed history, performing a physical examination, and documenting appropriate diagnoses to develop a comprehensive medical care plan and ensure capture of high-risk diagnoses under CMS guidelines.
• Performs episodic urgent medical visits to ensure that patients are given timely and appropriate medical care to avoid emergency room visits or hospitalization.
• Prescribes medically necessary and appropriate medications and treatments, in consultation with the physician where needed, including prescribing medication assisted treatment (MAT) for some conditions when clinically appropriate.
• Performs post discharge visits on patients within two weeks of discharge from either an acute care facility or a skilled nursing facility with the goal of decreasing admissions and re-admission; performs detailed medication reconciliation and adjust medications as indicated.
• Collaborates with inpatient or post-acute care team and patient to optimize discharge planning in collaboration with Transitions of Care (done in-person at facility, telephonically, or virtually).
• Leverage emergency medical or psychiatric services as indicated to mitigate Emergency Services and inpatient admissions.
• Documents all visits with focus on clear, comprehensive, and concise charting to identify, document, and execute a patient-centric plan of care.
• Serve as a clinical mentor for medical care.
• Proactively and collaboratively work with patients’ Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered.
• Identify and lead ad-hoc case reviews with internal/external care team as needed.
• Participates in committees and workgroups that promote clinical excellence and help to advance the organization's mission and business objectives.
• Assists leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
• Provide clinical coverage for colleagues as needed.
• Perform any other job related duties as requested.

Education and Experience

• Master's degree in Nursing or a degree in Physician Assistant Studies required
• Doctoral degree of Nursing Practice preferred
• Completion of accredited program and board certification as a Nurse Practitioner or Physician Assistant required
• Two (2) years of experience as NP or PA caring for patients with complex medical, behavioral health, and social needs; preferred experience in community setting required or
• One (1) year of experience as NP or PA in primary care or care management and
• Three (3) years experience as Registered Nurse or EMT-P in a high touch clinical environment or home care required or
• Five (5) years experience as Registered Nurse or EMT-P in a high touch clinical environment or home care required
• Experience with electronic medical record (eCW a plus) strongly preferred
• Experience working with managed care population preferred
• Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO) preferred

Competencies, Knowledge and Skills

• Proven skills, knowledge base, and judgment necessary for independent clinical decision making
• Excellent organizational, time management and problem-solving skills
• Ability to function effectively as part of a multi‐disciplinary team
• Strong and effective communication skills, written, verbal, and via electronic modalities
• Effective teaching skills
• Mediation and conflict resolution skills
• Ability to advocate for a complex patient population in a culturally competent manner
• Bilingual or multilingual preferred
• Ability to learn and utilize telehealth technologies (video, cha