Medical Matron

3 weeks ago

Syracuse NY, United States Wellbe Senior Medical Careers Full time

The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care - from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care. WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.


The Engagement Nurse Practitioner is responsible for modeling the WellBe values and mission in the care delivery for our patients. S/he is responsible for following the rules and regulations of state and federal regulatory agencies and any other certified agencies for their region. As an advanced practice provider at WellBe, you will play a vital role in the care for our patients in their home. This role is critical to our overall interdisciplinary team and focuses on providing compassionate care to the patients who have both chronic and acute illnesses and injuries while supporting their ability to stay in their own home. Our Engagement Nurse Practitioners make up our patient intake team and are dedicated to onboarding eligible patients onto the WellBe care model. Engagement Nurse Practitioners are focused on completing the initial visit and assessment that begins the patient’s longitudinal care with WellBe’s broader care team. In this role the Engagement Nurse Practitioner delivers primary care in the home-based setting for patients. The Engagement Nurse Practitioners is a critical member of the care team that will be accountable for not only engaging new patients, but also ensuring we have a comprehensive medical record on file for the patient by completing accurate, timely documentation of the patient records for these visits as part of our longitudinal model that will support transitioning these new patients to our longitudinal care Nurse Practitioners. The successful candidate works as part of our broader interdisciplinary team to assist in delivering concierge-style, timely and high-quality care to every patient.
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*To help our patients lead healthier, meaningful lives by delivering the most CompleteCare™ to their patient panel.
* Will primarily support in- home, patient-facing engagement visits to support patient care needs in the market.
* Responsible for engaging attributed patients into WellBe program and supporting care needs and efforts to keep patients engaged.
* Partners with other clinicians in the Care Community managing the health and wellbeing of
* Facilitates staff, patient, and family decision-making by providing educational resources.
* May also be scheduled visits to help address any urgent care needs of the market patients, including transition of care visits.
* Collaborates with community team to complete an initial welcome visit patient care assessment and plan.
* Delivers the highest standard of quality care while maintaining all company metrics pertaining to appropriate patient needs.
* Focuses clinical care delivery to support necessary items for documentation/coding, HEDIS measures, engagement of patients, and managing medical expenses.
* Serves as a key resource for patients in delivering ongoing care information, counseling and guidance for any patients with critical conditions.
* Utilizes all available resources to help care for patient needs and refers to internal/external resources as appropriate, such as WellBe behavioral health protocols.
* Adheres to a professional code of conduct in patient care delivery including completion of care needs and documentation standards.
* Previous experience in home care, primary care, hospice, palliative care, or geriatrics strongly preferred, other complex patient health care experience also beneficial (preferred)
* Have a valid driver’s license, car insurance, have access to a car and willingness to drive to patient
* Requires proof of an active auto insurance policy (required)

*Demonstrated role proficiency with Microsoft Office; Excel, Word, G-suite, etc.
* Proficient with office software, including Electronic Health Records, Scheduling Software and Ring Central applications
* Experience in diagnosing and treatment of ongoing, chronic and urgent medical/psychological conditions of older adults
* Experience in panel management, primary care, geriatrics, internal medicine, palliative care
* Experience in palliative care, and end-of-life communication
* Home care experience preferred
*Travel requirements: * Travel may be required up to 100% locally to deliver patient care.

*home, hospital, SNF, etc). Fine motor skills/Visual acuity.

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