Geriatric Advanced Practice Provider
About The Position
Medical Home Network (MHN) is hiring a Geriatric Advanced Practice Provider to deliver high-quality, patient-centered care to an aging population at partner health centers across the Chicago metro area, including Chicago, Berwyn, Waukegan, Evanston, Oak Park, and Melrose Park. The position reports to the Senior Medical Director and works onsite at partner health center locations. The provider will deliver billable clinical services in collaboration with contracted health centers, including Medicare Annual Wellness Visits and Advance Care Planning discussions. The role also contributes to the development, implementation, and scaling of clinical programs focused on preventive care, wellness, care coordination, and age-friendly care. It brings specialized geriatric expertise to community health centers that do not traditionally have dedicated geriatric services, with the goal of 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 helping ensure patients receive comprehensive, compassionate care. The provider will collaborate with interdisciplinary teams and contribute to program design, best practices, quality improvement, and continuous improvement. The position also directly manages Medical Assistant(s).
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.
- 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.
- Fluent Spanish speaker.
- Master’s degree or higher from an accredited Nurse Practitioner or Physician Assistant program.
Nice To Haves
- Experience working in FQHCs or similar community health settings is strongly preferred.
Responsibilities
- Provide comprehensive primary and preventive care services 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, preventive care planning, and referrals.
- Document care accurately and comply with regulatory and payer requirements.
- Identify gaps in care and initiate appropriate follow-up or care coordination.
- Lead patient-centered Advance Care Planning discussions with patients and families, assessing goals, values, and preferences for future medical care.
- Facilitate completion and documentation of advance directives, POLST/MOLST forms, and related Advance Care Planning documentation as appropriate.
- Collaborate with care teams so that patients’ 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).
Benefits
- Paid time off.
- Sick time.
- 12 paid holidays.
- Collaborative work environment with colleagues passionate about healthcare delivery.
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What This Job Offers
Job Type
Full-time
