About the position
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.
Job Summary
This role will travel to provide clinical services and train providers throughout AbsoluteCare's 5 markets in Ohio as assigned. Provider will be based in one of the 5 existing centers but is anticipated to travel to cover absences in other centers, assist during onboarding of new staff, and bridge gaps in care during certain times of the year. This provider will also see patients in their local intermediate care area, perform annual wellness visits, and provide hospital follow-up care. Provider may also see patients in the home-based setting. This role functions as part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.
Responsibilities
•Focus on the management and improvement of health for patients with multiple chronic medical conditions. Work with the interdisciplinary team supporting the care of these patients. Patients are all adults with occasional adolescents.
•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.
•Lead a travel team of a nurse practitioner, pod nurse, pod medical assistant, and administrative assistant in providing support as needed throughout the markets of Ohio.
•Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) in order 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 in order to help facilitate discharges.
•Treatment of 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/Solu-Medrol 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 is 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.
•Understand 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
•Assist with educating patients regarding their chronic diseases and healthy choices, disease progression, and the need for advanced directives.
•Practice evidenced-based care in accordance with the PCMH model of care.
•Able to keep track of and successfully attain specified quality metric goals.
•Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care is needed.
•Perform other duties as required consistent with chronic care and disease management services provided to patients.
•Participate in multi-disciplinary meetings and recommend treatment initiatives designed to keep patients healthy or resolve ongoing clinical issues.
•Provide on-call coverage for the office and hospital in rotation with other providers.
•Serve as a subject matter expert in the company's EHR, eCW, so that they may support and train other providers.
•Serve as a subject matter expert in risk adjustment, documentation of annual wellness visits, and closure of clinical quality gaps.
Requirements
•Licensed Nurse Practitioner in the state of practice.
•ACLS and BLS certification.
•Detailed knowledge of chronic disease management programs and services.
•Excellent organization and communication skills are necessary.
•Works well with a supervising physician.
•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.
•Experience with the management of Medicare, Medicaid, and commercial populations.
•Experience using EMR and efficiently completing notes within 48 hours.
•Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams.
•Innovative and creative self-starter to help solve patients' problems.
•Excellent interpersonal and communications skills.
•Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
•Working knowledge of Microsoft Office Suite (Word, Outlook, PowerPoint, and Excel).
Nice-to-haves
•Experience in population health management is preferred.
•Knowledge of managed care and insurance processes is preferred.
