Geriatric Advanced Practice Provider

Medical Home Network•Springfield, IL

5d•Onsite

About The Position

Medical Home Network is hiring a Geriatric Advanced Practice Provider to deliver high-quality, patient-centered care to an aging population at partner health center locations in Springfield and Decatur, Illinois. The provider will deliver billable clinical services in collaboration with contracted health centers, including Medicare Annual Wellness Visits and Advance Care Planning discussions, and will help build, implement, and scale programs focused on preventive care, wellness, care coordination, and age-friendly care. The role brings specialized geriatric expertise to community health centers that do not traditionally have dedicated geriatric services. The provider will guide care management efforts across the organization and collaborate with patients, caregivers, physicians, nurses, care managers, social workers, operations, clinical leadership, and quality teams. Responsibilities also include contributing to program design, clinical workflows, protocols, quality standards, and continuous improvement. The role directly manages Medical Assistant(s). Medical Home Network is a mission-driven public benefit corporation that partners with Federally Qualified Health Centers to improve safety-net care, reduce health disparities, and support value-based care through technology, care model innovation, and partnerships.

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.

Nice To Haves

Experience working in Federally Qualified Health Centers or similar community health settings.
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.
Fluency in Spanish.

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.
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; and preventive care planning and referrals.
Document services 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 to ensure Advance Care Planning 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 Annual Wellness Visits, Advance Care Planning, 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 about preventive care, aging-related health topics, and care planning.
Directly manage Medical Assistant(s).