Community Health Family Nurse Practitioner - NY

Vanna Health • New York, NY

6d

About The Position

Vanna Health is seeking an experienced, recovery-focused Family Nurse Practitioner who is passionate about community care, health education, and addressing 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 to improve health outcomes and quality of care.

The Family Nurse Practitioner conducts timely follow-up visits within seven days of discharge from an emergency department or inpatient setting, either in person in the field or via 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. It also addresses barriers to care, initiates or adjusts medications when members have difficulty engaging with community providers, offers same-day urgent visits, supports chronic disease management, facilitates preventive care, and participates in complex case reviews.

The practitioner works closely with Vanna Health’s interdisciplinary team to coordinate care, support continuity, address medical and behavioral health needs, and encourage engagement with outpatient services. Care may be delivered in member homes, in the community, or 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 in outpatient settings, including people with mental illness, substance use disorders, and multiple medical comorbidities.
• 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 to use Google, Slack, and Vanna EHR tools.
• Basic computer and phone skills.
• Valid driver’s license.
• Belief that individuals living 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 providing community-based 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 addressing 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 registered nurses, 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, diabetes screening for members taking antipsychotic medication, and colorectal cancer screening.
• Document all encounters and care coordination activities in a timely and compliant manner.
• Participate in team meetings, case reviews, and quality improvement initiatives.

Benefits

• Mileage reimbursement for field visits.
• Professional liability coverage.
• Reimbursement for costs associated with maintaining licensure, certification, and credentialing.
• Annual CME reimbursement allowance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed