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Experienced APP for Population Health Senior Health Services

4 months ago

Hampton VA, United States Sentara Medical Group Full time

Sentara Medical Group is searching for a Nurse Practitioner or Physician Assistant with at least 3 years post graduate experience in Internal Medicine or Family Medicine or geriatrics to join  Sentara Senior Health Services Home-Based Primary Care team , providing care to patients within the Peninsula region (30-mile radius from Sentara Hampton Careplex). The NP/PA will collaborate and partner with chronically ill or high-risk geriatric patients and their family/caregiver(s), clinic/hospital/skilled nursing facility providers and staff, and community resources in a team approach for post-discharge patients.

Highlights of this position include:
  • Schedule: 7:30AM - 5:00PM 4 days a week onsite; 1 day remote (4 hour admin block with remainder of day off)
  • In collaboration with PCPs or independently managing panel of own patients, conduct home visits for high-risk patients for AWV completion, Transitional Care Management, medication reconciliation, and acute or chronic disease management, while identifying any barriers to health within the home environment.
  • Provide timely access to appropriate care for post-discharge patients.
  • Serve as an integral part of the post-acute care strategy to effectively reduce hospital admissions/readmissions and potentially preventable Emergency Department visits.
  • Develop and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
  • Increase continuity of care by managing relationships with hospitalists, specialists, and those managing transitions of care
  • Collaborate with payer partners to engage high risk Medicare patients via virtual or home visits.
  • 100% home-based primary care, 4 days per week (1.0 FTE)

Requirements for this position include Graduate from an accredited School for Nurse Practitioners or Physician Assistants; 3 years post-graduate experience in Internal Medicine or Family Medicine in an outpatient clinic or hospital setting, Chronic disease management is a plus; NP or PA Virginia license; and, current DEA license. Candidates must have the ability to provide quality, comprehensive, continuity of medical care in a compassionate manner with minimum supervision.  Apply online at , keyword search JR-58342.