Advanced Practice Clinician, Integrated Care Delivery (San Bernardino County)

SCAN Health Insurance•San Bernardino, CA

10d•$125,400 - $179,300•Hybrid

About The Position

The Advanced Practice Clinician will provide and coordinate primary care to SCAN members to achieve the Company’s mission to keep seniors healthy and independent. This role involves providing care to an assigned panel of members in their place of residence, most commonly in senior living communities or skilled nursing facilities. Responsibilities include conducting physical/wellness exams and assessments, occasional urgent medical visits and telephonic triage, administering vaccines, ordering and interpreting diagnostic tests, initiating goals of care conversations, and chronic disease management. The clinician will identify patient health care needs, develop comprehensive plans of care, and collaborate with case management, Primary Care Physicians, specialists, hospitals, ancillary care providers, and community-based organizations to ensure continuity of care and advocate for members. This is a patient-facing role that requires independent management of visitation schedules, documentation of visits, and serving as a direct resource for members, families, and community staff. The role also involves participating in virtual health visits, an on-call program, educational workshops, and team efforts to meet quality healthcare goals. Employees may be eligible for differential pay. The company is seeking individuals who are curious about AI and its potential to transform operations and member service.

Requirements

Master’s degree in Nurse Practitioner Certificate OR Master’s from an accredited PA program, Education in Adult/Geriatric medical care preferred.
A comparable combination or education/experience and/or training will be considered equivalent to the education listed above.
Current California Nurse Practitioner license OR California Physician Assistant Certification (PA-C) in good standing.
Knowledge of the treatment of complex chronic diseases, such as dementia, diabetes, heart failure, and COPD.
Ability to identify health care needs and refer and coordinate with other resources/programs appropriately.
Knowledge of HCC and ICD-10 coding and documentation.
Knowledge of wound care and management.
Knowledge of CMS guidelines and Medicare Advantage Managed Care.
Comfortable with initiating goals of care and end of life discussions.
Strong interpersonal skills and change agent mindset needed to build relationships with healthcare team and patients.
Knowledge of and ability to maintain HIPAA requirements.
Adaptable and open to change and problem-solving.
Knowledge of and/or ability to learn basic technological skills (Word, Excel, PowerPoint, Outlook, EMR) and open to new technology.
Ability to stoop, kneel, and crouch required.
Ability to bend, reach, lift, pull, push, and carry up to 10 lbs. regularly and up to 50 lbs. occasionally.
Travel 75+% of the time in the assigned area- Must have a valid driver’s license, automobile insurance and reliable transportation.
Proof of Tuberculosis screening upon hire or providing proof of a negative screening within the last year.

Nice To Haves

Wound Care Certificate and Palliative Care Certificate a plus.
Multilingual/Multicultural a plus.

Responsibilities

Provide care to an assigned panel of members (patients) in their place of residence, most commonly in senior living communities or skilled nursing facilities.
Conduct physical/wellness exams and assessments.
Perform occasional urgent medical visits and telephonic triage to ensure timely, appropriate care and hospital avoidance if possible.
Administer vaccines.
Order and interpret diagnostic tests.
Initiate goals of care conversations with patients and their loved ones.
Manage chronic diseases.
Identify patient health care needs and develop a comprehensive plan of care for the patient, their family, and living-community staff.
Collaborate with the case management team to ensure members have timely access to necessary and appropriate services.
Independently manage visitation schedule in line with established practice protocols and adjust schedule based on members’ needs and acuity.
Engage with Primary Care Physicians and other health care professionals in a collaborative relationship aimed at disease prevention, health promotion, and chronic disease management.
Partner closely with Primary Care Physicians for clinical oversight and guidance.
Connect with specialists, hospitals, ancillary care providers, and community-based organizations to ensure continuity of care and promote shared decision-making while advocating for members.
Actively monitor and quickly address clinical quality gaps in care in partnership with other care providers.
Document member visits and interactions in a timely manner according to established practice protocols.
Serve as an ongoing direct resource for members and their families, as well as for their communities and support staff.
Participate with Integrated Care Sales team in events to build member awareness and educate communities.
Initiate and complete virtual health visits with members as needed to promote accurate triaging and reduce drive time.
Participate in on-call program available to our members after hours and on weekends.
Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications.
Contribute to team efforts to meet quality healthcare goals by closing care gaps, attending high risk group discussions, and optimizing clinical workflows and protocols.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.