Community Health Specialist
4 weeks ago
At AbsoluteCare, we are seeking a highly skilled and compassionate Community Based Advance Practice Provider to join our team. As a key member of our healthcare team, you will provide high-quality, patient-centered care to our community-based patients.
Job Summary:The Community Based Advance Practice Provider will provide medical and care-coordination services to patients in their homes, focusing on managing transitions of care and collaborating with current care providers. This is a unique opportunity to make a meaningful impact on the lives of vulnerable patients and contribute to the development of our community-based care model.
Responsibilities:- Provide community-based medical and care-coordination services to patients in their homes.
- Manage a small panel of homebound patients who require primary care.
- Resolve acute issues in the home and clinic or by directing patients to the most effective and efficient solutions.
- Ensure coordination of care, including timely and accurate completion of chart documents, communication with the Core Clinical Team, and collaboration with the Integrated Care Team.
- Identify and refer patients to specialty programs when instability or crisis occurs.
- Implement transitional care protocols and help patients identify barriers to meeting health and life goals.
- Adjust care plans following guidelines for evidence-based chronic disease management.
- Educate and coach patients for medication adherence and chronic disease self-management skill development.
- Monitor patients at risk of being lost to care and implement interventions to prevent loss.
- Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
- ACLS certified.
- Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
- Ability to meet deadlines and manage multiple priorities.
- Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
- Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
- Excellent computer skills, including knowledge of Microsoft Office.
- Patient-centered focus.
- Familiar with care transitions, strategies for reducing readmissions, and chronic condition management interventions.
- Experience in a Patient Centered Medical Home.
- Experience working with high-risk and medically complex patients with multiple comorbidities.
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