Community Health Family Nurse Practitioner - NY
About The Position
Vanna Health is seeking an experienced, recovery-focused Family Nurse Practitioner who is passionate about community care, health education, and supporting all dimensions of wellbeing. The role serves individuals with mental illness and chronic physical health conditions in the New York City area, helping them access community-based care and improve health outcomes and quality of care. The FNP conducts timely follow-up visits within one week of discharge from an emergency department or inpatient setting, either in person in the field or through telehealth, with the goal of reducing 30-day readmissions and emergency department re-presentations. The role supports medication adherence through education, medication reconciliation, and bridge prescriptions as needed; addresses barriers to care; and initiates or adjusts medications when members have difficulty engaging with community providers. The FNP also provides same-day urgent visits, supports chronic disease management for high utilizers with complex conditions, facilitates preventive care, and participates in complex case reviews. Working closely with Vanna Health’s interdisciplinary team, the FNP coordinates care to promote continuity, address medical and behavioral health needs, and support engagement with outpatient services. Care is delivered in the community, including member homes, and via telehealth.
Requirements
- Active, unencumbered New York State Nurse Practitioner license in good standing with prescriptive authority.
- Board certification as a Family Nurse Practitioner (FNP-C).
- Ability to obtain credentialing with Optum.
- Experience working with complex patients, including people with mental illness, substance use disorders, and multiple medical comorbidities in an outpatient setting.
- Demonstrated experience working in interdisciplinary care teams.
- Strong care coordination, communication, and organizational skills.
- Ability to work independently in field-based and telehealth settings.
- Willingness to learn Google, Slack, and Vanna EHR tools.
- Basic computer and phone skills.
- Valid driver’s license.
- Belief that individuals with mental illness can recover and achieve life goals when provided opportunity, support, and community.
Nice To Haves
- Multi-state licensure.
- Credentialing with New York State Medicaid.
- Experience in transitional care, care management, or population health.
- Familiarity with Medicaid populations and value-based care models.
- Experience conducting home visits or community-based care.
- Background in collaborative care.
Responsibilities
- Deliver direct clinical care in the community, including member homes, and via telehealth.
- Conduct post-discharge follow-up visits within seven days for eligible members.
- Perform comprehensive clinical assessments covering medical and behavioral health needs.
- Conduct annual wellness visits for eligible members.
- Prescribe and administer long-acting antipsychotic medications and monitor vital signs.
- Conduct specified point-of-care screening and laboratory testing.
- Develop and implement care plans in collaboration with an interdisciplinary team.
- Coordinate care with internal team members, including RNs, physicians, coaches, community health workers, and peer specialists.
- Liaise with external outpatient providers and payer care managers to support continuity of care and appropriate follow-up.
- Identify and address barriers to care, including social determinants of health.
- Support efforts to reduce 30-day emergency department revisits and hospital readmissions.
- Ensure members are up to date on preventive care and screenings, including breast cancer screening, annual eye exams for members with diabetes mellitus, diabetes screening for members taking antipsychotic medication, and colorectal cancer screening.
- Document encounters and care coordination activities in a timely and compliant manner.
- Participate in team meetings, case reviews, and quality improvement initiatives.
- Support medication adherence through education, medication reconciliation, and bridge prescriptions as needed.
- Offer same-day urgent visits, optimize chronic disease management for high utilizers, and initiate or adjust medications when members face challenges engaging with community providers.
Benefits
- Mileage reimbursement for field visits.
- Professional liability coverage.
- Reimbursement for costs associated with maintenance of licensure, certification, and credentialing.
- Annual CME reimbursement allowance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
