CareConnect Advanced Practice Provider- [Triage / Resource]

Wellbe Senior Medical•Chicago, IL

About The Position

The WellBe care model is a physician-led, Advanced Practice clinician-driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care – from chronic care and urgent care in the home, to hospital, to skilled nursing facilities, to assisted living, to palliative care, to end of life care. Our WellBe physician/advanced practicing clinician-led geriatric care teams partner with the patient’s primary care physician to provide concierge-level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum. GENERAL SUMMARY The Advanced Practice Practitioner is responsible for modeling the WellBe values and mission in care delivery for our patients. S/he is responsible for following the rules and regulations of state and federal regulatory agencies and any other certified agencies for their region. As an advanced practice provider at WellBe, you will play a vital role in the care for our patients in their home via remote care. This role is critical to our overall interdisciplinary team and focuses on providing compassionate care to patients who have both chronic and acute illnesses and injuries while supporting their ability to stay in their own home. This role provides clinical triage, clinical management, and clinical oversight for unscheduled needs, working in telephonic/ video visits or in home clinical care visit, and working in collaboration with other healthcare professionals on the team. The Advanced Practice Practitioner role is a key member of the team that will be accountable for providing the overseeing urgent care services to a wide variety of patients, maintaining accurate, timely and current patient records, and will as part of our longitudinal model will support assuring patients are compliant with protocols, HEDIS and transition of care needs and regularly schedule follow up appointments as needed to care for their health needs. The successful candidate works as part of our broader interdisciplinary team to assist in delivering concierge-style, timely and high-quality care to every patient. This role will be in multiple locations

Requirements

Minimum of Master's Degree, Nursing with focus on Family Nurse Practitioner, Adult Nurse Practitioner, Geriatric Nurse Practitioner or Adult-Geriatric Nurse Practitioner from an accredited, Nurse Practitioner program (required)
Active, unencumbered Nurse Practitioner license in the state of job posting and must reside in state (required)
Current board certification in your field with either ANCC (American Nurses Credentialing Center) or AANP (American Association of Nurse Practitioners) (required)
BLS certified and an active NPI# as an NP (required)
Active, unencumbered DEA licensure or eligibility to obtain (required)
Ability to conduct in-home setting visits remotely and in person while having previous experience on a telehealth platform
Demonstrated role proficiency with Microsoft 365 software suite, Office; Excel, Word, G-suite, etc.
Proficient with office software, including Electronic Health Records, Scheduling Software and Ring Central applications
Ability to work independently and make sound decisions while adhering to established protocols and guidelines.
Excellent organizational and time management skills to handle administrative tasks and facilitate telehealth consultations.
Experience working with culturally diverse and underserved populations.
Experience in diagnosing and treatment of ongoing, chronic and urgent medical/psychological conditions of older adults
Role model in courageous teamwork, integrity, ethics, and productivity
Experience in panel management, primary care, geriatrics, internal medicine, palliative care
Experience in palliative care, and end-of-life communication
Excellent verbal, written, presentation, and interpersonal communication skills
Confident speaker to internal and external groups
Additional state licenses preferred
This role will be in multiple locations

Nice To Haves

3-5 years Nurse Practitioner experience (preferred)
Previous experience in value-based care, home care, primary care, hospice, palliative care, or geriatrics strongly preferred, other complex patient health care experience also beneficial (preferred)
Experience with telehealth care delivery (highly preferred)
Home care experience preferred.

Responsibilities

Practices the WellBe mission: To help our patients lead healthier, meaningful lives by delivering the most CompleteCare™ to their patient panel.
Partners with other clinicians including community medical directors, longitudinal advanced practice providers, and community social workers managing the health and wellbeing of patients living in their homes.
Responsible for supporting care needs and efforts to keep patients engaged.
Facilitate in-home + telehealth visits, including initial patient assessments and ongoing follow-up visits as appropriate per patient need.
Facilitates staff, patient, and family decision-making by providing educational resources.
Performs urgent care services, needed patient screenings/physical examinations, creates appropriate assessment/plan, and completes documentation in a timely manner.
Addresses any care needs of the patients as needed, including transition of care visits and HEDIS measures.
Collaborates with community team to complete a full patient care assessment and plan.
Orders, interprets, and analyzes diagnostic tests and determines the need for follow-up. appointments and further treatment options per state supervisory agreement.
Prescribes and manages medications and treatments as appropriate, including but not limited to psychopharmacological agents per state supervisory agreement.
Updates patient records and checks records for accuracy at each patient's appointment.
Delivers patient care and completes regular patient reviews with supervising/collaborating physicians per state supervisory agreement.
Delivers the highest standard of quality care while maintaining all company metrics pertaining to appropriate patient needs.
Focuses clinical care delivery to support necessary items for documentation/coding, HEDIS measures, engagement of patients, and managing medical expenses.
Serves as a key resource for patients in delivering ongoing care information, counseling and guidance for any patients with critical conditions.
Utilizes all available resources to help care for patient needs and refers to internal/external resources as appropriate, such as WellBe behavioral health protocols.
Collaborates with the interdisciplinary team and participates in regularly scheduled team meetings.
Maintains required unencumbered, active state licensure(s) and national certification(s).
Deliver palliative care, and when needed, support end of life care to patients and families.
Facilitates family meetings with WellBe community team, to help with complicated family dynamics and goals of care.
Adheres to a professional code of conduct in patient care delivery including completion of care needs and documentation standards.
Other tasks needed to accomplish organizational objectives/goals.