Complex Care Provider

Adobe Care And Wellness LLC

9h•Remote

About The Position

As a Complex Care Provider, you will deliver exceptional remote care via our telemedicine platform in a compassionate manner. In this team-based model, you will be a licensed Nurse Practitioner (NP), Physician Assistant (PA), or Medical Doctor (MD/DO) who is a key member of the Population Health team, dedicated to delivering comprehensive, patient-centered care for adults with complex medical, emotional, and social needs, as well as chronic, acute, preventive, and palliative care needs. Supported by nurses in the field and a robust administrative team, you will leverage telemedicine tools to deliver high-quality, patient-centered care. This role emphasizes longitudinal care, preventive and chronic disease management, and innovative approaches to address health disparities and improve patient outcomes.

Requirements

Minimum of 3 years of clinical experience with strong clinical skills, with a focus on complex care or population health.
Experience in primary care, preferably with geriatric and palliative care patients.
Proven ability to manage a patient panel and provide longitudinal care.
Comfortable collaborating with nurses and other team members in the care process.
Compassionate and empathetic, with a commitment to serving patients with complex medical and social needs.
Organized, flexible, and innovative with a problem-solving mindset.
Proficient in telemedicine technology, including EHR systems and videoconferencing platforms.
Active and unrestricted licensure as a Nurse Practitioner (NP), Physician Assistant (PA), or Medical Doctor (MD/DO) in the state of California is REQUIRED.

Nice To Haves

Board Certified or Board Eligible in Internal Medicine, Family Medicine, or Geriatrics is preferred.
Familiarity with telemedicine platforms and digital health tools.
Spanish language skills preferred but not required.

Responsibilities

Develop and implement individualized care plans in collaboration with patients, families, and interdisciplinary team members.
Coordinate care across primary care, specialty providers, behavioral health, and community resources.
Facilitate transitions of care to prevent readmissions and ensure continuity.
Diagnose, assess, and treat a variety of medical conditions, particularly those related to chronic health issues.
Develop and implement individualized care plans that address physical, emotional, and social needs.
Provide clinical care, including assessment, treatment, and monitoring of acute and chronic conditions, adhering to evidence-based guidelines.
Provide comprehensive care for an adult patient panel, including chronic condition management, preventive care, and acute or palliative care as needed.
Perform in-home visits, telehealth, and clinic-based care to meet patient needs.
Offer patient education on disease management, medication adherence, and preventive health.
Address behavioral health concerns by collaborating with mental health professionals and integrating behavioral health into care plans.
Identify and mitigate social determinants of health, such as housing instability, food insecurity, and transportation barriers, by connecting patients with community resources.
Engage in longitudinal care, building relationships with patients and managing their health over time.
Engage in population health initiatives, using data to identify trends and develop strategies to improve care delivery.
Track and document patient outcomes to assess the effectiveness of interventions.
Participate in quality improvement initiatives aimed at reducing disparities and enhancing care delivery.
Utilize population health data to identify at-risk individuals and proactively manage their care.
Utilize telemedicine technology for video consultations, EHR documentation, and patient interactions.
Innovate and adapt to novel care models that meet the complex medical and social needs of patients.
Work closely with interdisciplinary teams, including physicians, nurses, social workers, and case managers, to ensure comprehensive care, seamless scheduling, records retrieval, and rapid check-ins.
Communicate effectively with patients and families, respecting their cultural, linguistic, and personal preferences.
Collaborate with field-based nurses to deliver integrated care and support patient self-management skills.
This position requires participation in an on-call rotation to provide support outside of standard business hours.
Responding to urgent issues or emergencies as they arise.
Being accessible and available via phone, email, or other designated communication tools during on-call shifts.
Addressing incidents or escalating them as necessary to ensure timely resolution.
Maintaining documentation of on-call activities and resolutions.
On-call shifts may include evenings, weekends, and holidays, as determined by the department schedule. Candidates must demonstrate flexibility and the ability to adapt to unexpected situations during on-call periods.