Job Description

Job Description

Community Based / Urgent Care Clinician provides needed primary care and urgent care in the home and Care Center. Great focus on managing transitions of care, especially in the important and delicate time after hospital discharge. This position adds to a member’s current care, collaborating with their current care providers. The role is immensely satisfying, as you practice enhanced primary care and have the benefit of expert care management. Seeing members in the home allows you great insight into the social factors that affect their care. This is a tremendous opportunity to impact the care of vulnerable patients. Provider is responsible for patient visits to manage acute onset of a new illness, acute exacerbations of chronic conditions and members needing reassurance that a trip to the ER is not a necessity.

The provider will support long term management of chronic conditions by providing a platform to discuss exacerbating factors in real time as well as potential behavioral modifications which can prevent a recurrence.

Duties And Responsibilities

Provide on-site & home visit clinical care to include:

• Acute onset of a new illness.
• Evaluation of acute exacerbations of chronic conditions.
• Shortness of breath without chest pain, change in mental status or new onset hypoxia.
• CHF exacerbations
• Asthma/COPD exacerbations
• Bronchitis/pneumonia
• Hyperglycemia
• Elevated blood pressure
• Evaluation and treatment of a variety of infections
• New or worsening aches or pains, wounds, depression and/or anxiety.
• Members we know will go to the ER if not seen today.
• Hospital follow-ups not able to be seen by Primary Care Provider.

Ensure Coordination Of Care To Include

• Timely and accurate completion of chart documents.
• Work with Treatment and Triage Nurse to address sick calls and visits requiring Provider management.
• Receive input from the Core Clinical Team (PCP, Care Manager or SW) to define visit goals.
• Communicate important post visit follow up information to Core Clinical Team.
• Collaborate with Integrated Care Team (ICT) members (behavioral health, nutrition, health education) for problem solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs such as: abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
• Implement transitional care protocols as part of warm hand offs between internal and external care providers.
• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
• Adjust care plan following guidelines for evidenced based chronic disease management.
• Educate and coach for medication adherence and chronic disease self-management skill development.
• Monitor members at risk of being lost to care and implement interventions to prevent loss.

Education & Experience Requirements

• Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
• ACLS certified.
• Must be willing to do home visits as needed. This position is both clinic based and community based.
• 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.
• Success 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 in a Patient Center Medical Home.
• Experience working with high risk and medically complex patients with multiple comorbidities.

Job Tags

Work at office,

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