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Health Guide

1 month ago

Fairfax VA United States Firsthand Full time

The Health Guide is a licensed Nurse Practitioner or Physician Assistant who leads the medical aspects of team-based care for individuals with serious mental illness that firsthand serves. The Health Guide is responsible for whole person assessment and management of our vulnerable population, collaborating closely with community primary care and behavioral health providers, as well as an internal team of firsthand Guides (peers) and Community Resources Guides (social services personnel).

The Health Guide assists other members of the firsthand Care Team such as the firsthand Guide (peer specialist) in supporting individuals achieving recovery, and the Community Resources Guide in meeting SDOH needs and with disability applications.

As a Health Guide, you will perform a whole-person clinical assessment, including:

* Assessing both behavioral and physical health conditions with a thorough history and physical examination; Capturing conditions not yet diagnosed, ordering additional studies where indicated to confirm or rule out the diagnosis
* Collaborating with a team of support including medical records and clinical documentation specialists, certified coders, and medical assistants
* Conducting visits in the in the office, virtually, in the field, or in an individual's home when needed
* Making individualized recommendations and/or referrals for programs/care provided by firsthand and/or outside providers, based on the assessed need
* Supporting individuals in developing and exercising self management skills and person-centered care around their individual goals and preferences via motivational interviewing and holistic care planning
* Organizing the information in a manner that supports appropriate clinical documentation and successful disability applications (if appropriate)

Lead the medical component of the team-based care provided by firsthand, including:

* Training and advising roles like Medical Assistants, and Peer Recovery Specialists on behavioral, clinical, and social health priorities
* Supporting Guide Team on care coordination
* Leading care and disease management - identifying actionable care gaps
* Communicating and coordinating with individuals' care providers, primarily at CMHCs, FQHCs, and hospitals
* Providing direct patient care when needs cannot be met by existing community providers
* Perform in-home and in-clinic phlebotomy as needed

Collaborate with other team members to provide integrated care

* Assist firsthand Guides (peer specialists) with engagement and recovery support
* Assist Community Resources Guides with addressing SDOH and disability applications

You will be a good fit if you have:

* Excellent clinical acumen in outpatient chronic disease and behavioral health care
* Empathy, compassion, and approachability
* Excellent listening, communication, and interpersonal skills
* Desire to help people in need and support their path to wellness
* Comfort working as part of a multidisciplinary team, and enjoy mixed roles and duties - this is a mix of direct service, teaching, and care management
* Cultural humility, knowledge of trauma informed care, and social determinants of health
* Desire to perform data driven care
* Familiarity with local providers
* Ability to maintain professional boundaries and engagement skills with a population with challenges and in non-traditional work conditions
* Intermediate computer and typing proficiency - experience with Electronic Health Records, familiarity with Google Suite a plus
* Ability to operate a vehicle, including a driver's license that is active and in good standing; must be eligible to drive under Company insurance policy

The experience you bring to this role includes:

* 5+ years clinical care as a Nurse Practitioner or Physician Assistant, ideally in a primary care setting
* Working with and managing a population with challenges such as behavioral health and/or SUD conditions
* Developing and delivering educational programs to nurses and affiliated medical staff
* Care management and coordination

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