Primary Care Nurse Practitioner
3 weeks ago
Exciting Opportunity Ahead
We are thrilled to announce the upcoming opening of a new medical center As we finalize the details, stay tuned for updates about this incredible addition to our network
Join AbsoluteCare in Making a Difference
At AbsoluteCare, we are committed to serving our most vulnerable communities. Our members are often individuals with multiple chronic illnesses or those facing unequal access to healthcare, frequently relying on emergency rooms for basic care. We redefine this experience by offering focused care that addresses both their medical needs and the social factors impacting their lives.
Our unique model transforms traditional healthcare into a comprehensive care center where our members receive coordinated support from doctors, nurses, social workers, and medical assistants—all in one place. We provide essential services like pharmacy, X-rays, labs, and more to enhance the care experience.
Our team doesn’t just work within our walls; we engage with our community to discover and support those in need. Our innovative model—guided by our core values of accountability, caring, trust, and teamwork—proves that our approach truly works.
About the Role
The Community-Based Clinician will provide essential primary and urgent care services right in the home, focusing on managing transitions of care, especially after hospital discharge. This fulfilling role allows you to collaborate closely with existing care providers while impacting the health of vulnerable patients through enhanced primary care.
Key Responsibilities:
- Deliver community-based medical care and coordination for individuals recently discharged from the hospital.
- Manage a small panel of homebound members requiring primary care.
- Address acute medical issues either in-home, clinic, or through appropriate referrals.
- Conduct in-home clinical assessments for conditions such as:
- New illnesses and acute exacerbations of chronic conditions.
- Shortness of breath without chest pain, new onset hypoxia, or change in mental status.
- CHF, asthma, and COPD exacerbations.
- Infections, hyperglycemia, and elevated blood pressure.
- Aches, pains, wounds, anxiety, or depression requiring urgent attention.
- Members at high risk of ER visits if not seen promptly.
Care Coordination Duties Include:
- Timely and accurate chart documentation.
- Collaborate with the Treatment and Triage Nurse to handle sick calls efficiently.
- Define visit goals with the Core Clinical Team (PCP, Care Manager, or SW).
- Communicate vital follow-up information post-visit to the Core Clinical Team.
- Work with Integrated Care Team members (behavioral health, nutrition) for coordinated problem-solving.
- Identify and refer members to specialty programs for issues like abuse, neglect, housing crises, and food insecurity.
- Implement transitional care protocols and ensure warm hand-offs between care providers.
- Assist patients in identifying barriers to achieving health and life goals, connecting them with necessary resources.
- Modify care plans based on evidence-based chronic disease management guidelines.
- Educate members on medication adherence and chronic disease self-management.
- Monitor members at risk of falling out of care and implement preventive interventions.
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