Advanced Practice Clinician, Integrated Care Specialist
2 weeks ago
The Advanced Practice Clinician will provide and coordinate primary care to SCAN members to achieve the Company's mission to keep seniors healthy and independent.
Key Responsibilities- Provide care to an assigned panel of members (patients) in their place of residence, most commonly in senior living communities or skilled nursing facilities.
- Conduct physical/wellness exams and assessments; occasional urgent medical visits and telephonic triage to ensure timely, appropriate care and hospital avoidance if possible; administer vaccines; order and interpret diagnostic tests; initiate goals of care conversations with patients and their loved ones; and chronic disease management.
- Identify patient health care needs and develop a comprehensive plan of care for the patient, their family, and living-community staff.
- Collaborate with our case management team to ensure members have timely access to necessary and appropriate services.
- Independently manage visitation schedule in line with established practice protocols and adjust schedule based on members' needs and acuity.
- Engage with Primary Care Physicians and other health care professionals in a collaborative relationship aimed at disease prevention, health promotion, and chronic disease management.
- Partner closely with Primary Care Physicians for clinical oversight and guidance.
- Connect with specialists, hospitals, ancillary care providers, and community-based organizations to ensure continuity of care and promote shared decision-making while advocating for members.
- Actively monitor and quickly address clinical quality gaps in care in partnership with other care providers.
- Document member visits and interactions in a timely manner according to established practice protocols.
- Serve as an ongoing direct resource for members and their families, as well as for their communities and support staff.
- Participate with Integrated Care Sales team in events to build member awareness and educate communities.
- Initiate and complete virtual health visits with members as needed to promote accurate triaging and reduce drive time.
- Participate in on-call program available to our members after hours and on weekends.
- Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications.
- Contribute to team efforts to meet quality healthcare goals by closing care gaps, attending high risk group discussions, and optimizing clinical workflows and protocols.
- Actively support the achievement of SCAN's Vision and Goals.
- Master's degree in Nurse Practitioner Certificate OR Master's from an accredited PA program, Education in Adult/Geriatric medical care preferred.
- A comparable combination or education/experience and/or training will be considered equivalent to the education listed above.
- Current California Nurse Practitioner license OR California Physician Assistant Certification (PA-C) in good standing.
- Wound Care Certificate and Palliative Care Certificate a plus.
- Knowledge of the treatment of complex chronic diseases, such as dementia, diabetes, heart failure, and COPD.
- Ability to identify health care needs and refer and coordinate with other resources/programs appropriately.
- Knowledge of HCC and ICD-10 coding and documentation.
- Knowledge of wound care and management.
- Knowledge of CMS guidelines and Medicare Advantage Managed Care.
- Comfortable with initiating goals of care and end of life discussions.
- Strong interpersonal skills and change agent mindset needed to build relationships with healthcare team and patients.
- Knowledge of and ability to maintain HIPAA requirements.
- Adaptable and open to change and problem-solving.
- Knowledge of and/or ability to learn basic technological skills (Word, Excel, PowerPoint, Outlook, EMR) and open to new technology.
- Ability to stoop, kneel, and crouch required. Ability to bend, reach, lift, pull, push, and carry up to 10 lbs. regularly and up to 50 lbs. occasionally.
- Multilingual/Multicultural a plus.
- Travel 75+% of the time in the assigned area- Must have a valid driver's license, automobile insurance and reliable transportation.
- Base salary range: $125,400.00 to $200,600.00 annually
- Quarterly bonus program
- Robust Wellness Program
- Generous paid-time-off (PTO)
- Eleven paid holidays per year, plus 1 additional floating holiday, plus one birthday holiday
- Excellent 401(k) Retirement Saving Plan with employer match and contribution
- Robust employee recognition program
- Tuition reimbursement
- An opportunity to become part of a team that makes a difference to our members and our community every day
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