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 deliver high-quality, patient-centered care to older adults enrolled in its contracted health centers. Reporting to the Senior Medical Director, the provider will deliver billable clinical services in collaboration with health centers, including Medicare Annual Wellness Visits (AWVs) and Advance Care Planning (ACP) discussions. The role also contributes to the design, implementation, and scaling of clinical programs for preventive care, wellness, care coordination, and age-friendly care. This position brings geriatric expertise to community health centers that traditionally do not have dedicated geriatric services and supports MHN’s broader care delivery and care management initiatives.

The provider will conduct comprehensive primary and preventive care, assessing chronic conditions, functional status, cognitive health, fall risk, and medication needs. They will develop individualized care plans with patients, caregivers, and interdisciplinary teams; lead sensitive conversations about patients’ goals and preferences for future care; and help ensure care preferences are documented and honored. The provider will also help establish workflows, clinical protocols, and quality standards, contribute to continuous improvement, and directly manage Medical Assistant(s).

The role works onsite at partner health center locations across the Chicago metro area, including Chicago, Berwyn, Waukegan, Evanston, Oak Park, and Melrose Park. The anticipated start date is January 2027. MHN is a mission-driven public benefit corporation that partners with Federally Qualified Health Centers (FQHCs) to advance value-based care, reduce health disparities, and build healthier communities.

Requirements

• Active, current, unrestricted Nurse Practitioner or Physician Assistant license in Illinois.
• National Nurse Practitioner certification through AANP or ANCC, or Physician Assistant certification.
• Experience in geriatric care.
• Demonstrated experience conducting Annual Wellness Visits and Advance Care Planning discussions.
• Strong communication skills and comfort with sensitive conversations.
• Master’s degree or higher from an accredited Nurse Practitioner or Physician Assistant program.
• Fluent Spanish speaker.

Nice To Haves

• 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.

Responsibilities

• Provide comprehensive primary and preventive care to aging patients enrolled in MHN-contracted health centers.
• Assess chronic disease management, functional status, cognitive health, fall risk, and medication management needs.
• Develop individualized, patient-centered care plans 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, preventive care planning, and referrals.
• Document visits accurately and comply with regulatory and payer requirements.
• Identify gaps in care and initiate follow-up or care coordination.
• Lead patient-centered Advance Care Planning discussions with patients and families, assess goals and preferences, and facilitate completion and documentation of advance directives and POLST/MOLST forms as appropriate.
• Collaborate with care teams so ACP preferences are understood and honored across settings.
• Contribute to designing, implementing, and scaling 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 with physicians, nurses, care managers, social workers, and other interdisciplinary team members.
• Support quality improvement initiatives, documentation accuracy, and value-based care performance metrics.
• Educate patients, caregivers, and staff on preventive care, aging-related health topics, and care planning.
• Directly manage Medical Assistant(s).

Benefits

• Paid time off
• Sick time
• 12 paid holidays
• Fun, challenging, and collaborative work environment with passionate colleagues

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level