Community Health Nurse Practitioner - Marioin County, IN

Vanna Health, Inc•Indianapolis, IN

4d•$105,000 - $115,000•Hybrid

About The Position

Vanna Health is seeking an experienced, recovery-focused Family Nurse Practitioner (FNP) who is passionate about community care, health education and facilitating care that addresses all the dimensions of wellbeing. In this role, you will bring passion for serving individuals with mental illness and chronic physical health conditions, helping them access community-based care to improve health outcomes and quality of care for members of our Indiana locations in Marion, Lake, Allen and Vanderburgh counties. This role focuses on conducting timely follow-up visits with members, within 1 week of discharge from the emergency department (ED) or inpatient setting for a behavioral health-related reason, either in-person in the field or via telehealth, with the goal of reducing 30-day readmissions and ED re-presentations. The FNP will support member medication adherence through education, medication reconciliation and bridge prescriptions as needed. The FNP will also address barriers to primary care access offering same-day urgent visits to help avoid unnecessary ED utilization, medication management and optimizing chronic disease management for high utilizers with complex conditions, and participating in complex case reviews. The FNP will play a key role in care coordination, working closely with Vanna Health’s interdisciplinary team to ensure continuity of care, address medical and behavioral health needs, and support engagement with outpatient services. This position offers a flexible hybrid care delivery approach across multiple care settings with a primary base in the Indianapolis office. The role requires a strong in-person clinical presence with the flexibility of remote/telehealth coverage as clinically appropriate to support enhanced patient access to primary and behavioral health care.

Requirements

Active and unencumbered Indiana State Nurse Practitioner license in good standing with prescriptive authority
Board certification as a Family Nurse Practitioner (FNP-C)
Credentialed with Indiana State Medicaid
Ability to obtain credentialing with Carelon (Anthem)
Experience working with complex patients, including those with mental illness, substance use disorders, and multiple medical comorbidities in the outpatient setting
Demonstrated experience working in interdisciplinary care teams
Strong care coordination, communication, and organizational skills
Ability to work independently in both field-based and telehealth settings
Willingness to learn how to work with Google, Slack, and Vanna EHR tools
Basic computer and phone skills
A valid driver’s license
Belief that individuals suffering from mental illness can and will recover to achieve life goals when provided the opportunity, support, and community

Nice To Haves

Multi-state licensure
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-person in the community, including member homes or via telehealth, including:
Conduct post-discharge follow-up visits within 7 days
Perform comprehensive clinical assessments, including medical and behavioral health needs
Prescribe and administer long-acting antipsychotic medications and monitoring of vital signs
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 to ensure continuity of care and appropriate follow-up
Identify and address barriers to care, including social determinants of health
Support efforts to reduce 30-day ED revisits and hospital readmissions
Ensure members are up to date on recommended preventive care and screenings (e.g., breast cancer screening, annual eye exams for members with Diabetes Mellitus)
Document all encounters and care coordination activities in a timely and compliant manner
Participate in team meetings, case reviews, and quality improvement initiatives