Geriatric Advanced Practice Provider

Medical Home Network•Chicago, IL

3d•Onsite

About The Position

Medical Home Network (MHN) is seeking a Geriatric Advanced Practice Provider to join their team. MHN partners with Federally Qualified Health Centers (FQHCs) nationwide to transform care, reduce health disparities, and build healthier communities. This role is crucial in delivering high-quality, patient-centered care to an aging population, focusing on preventive care, wellness, care coordination, and age-friendly care models. The provider will conduct billable clinical services, including Annual Wellness Visits (AWVs) and Advance Care Planning (ACP) discussions, at partner health centers across the Chicago metro area. This position brings specialized geriatric expertise to community health centers that traditionally lack dedicated geriatric services, enhancing the level and quality of care for seniors in under-resourced communities. The role supports MHN's broader care delivery initiatives by guiding care management efforts and ensuring comprehensive, compassionate patient care.

Requirements

Active Nurse Practitioner license (OK)
National NP certification (AANP or ANCC) or PA certification
Experience in geriatric care required
Demonstrated experience conducting AWVs and ACP discussions
Strong communication skills and comfort with sensitive conversations
Experience working in FQHCs or similar community health settings is strongly preferred.
Prior experience building or scaling clinical programs
Experience with primary care or population health
Background in value-based care, risk adjustment, or quality initiatives
Familiarity with EHR documentation and Medicare compliance
Experience working with interdisciplinary or care management teams
Master’s degree or higher from an accredited Nurse Practitioner or Physician Assistant program
Current, unrestricted Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of OK.

Nice To Haves

Fluent Spanish speaker preferred

Responsibilities

Provide comprehensive primary and preventive care services to aging patients enrolled in MHN’s contracted health centers.
Perform thorough assessments focusing on chronic disease management, functional status, cognitive health, fall risk, and medication management.
Develop individualized, patient-centered care plans in collaboration with patients, caregivers, and interdisciplinary teams.
Conduct Medicare Annual Wellness Visits, including health risk assessments, cognitive and depression screenings, fall risk and functional assessments, medication reconciliation, and preventive care planning and referrals.
Ensure accurate documentation and compliance with regulatory and payer requirements.
Identify gaps in care and initiate appropriate follow-up or care coordination.
Lead compassionate, patient-centered Advance Care Planning discussions with patients and families.
Assess patient goals, values, and preferences for future medical care.
Facilitate completion and documentation of advance directives, POLST/MOLST forms, and related ACP documentation.
Collaborate with care teams to ensure ACP preferences are understood and honored across settings.
Contribute to the design, implementation, and scaling of clinical programs focused on geriatric care, preventive services, and population health.
Help define workflows, clinical protocols, and quality standards for AWVs, ACP, and related initiatives.
Partner with operations, clinical leadership, and quality teams to improve efficiency, outcomes, and patient experience.
Work closely with physicians, nurses, care managers, social workers, and other interdisciplinary team members.
Support quality improvement initiatives, documentation accuracy, and performance metrics related to value-based care.
Educate patients, caregivers, and staff on preventive care, aging-related health topics, and care planning.
Directly manage Medical Assistant(s).