Advanced Practice Provider

2 weeks ago

Philadelphia, Pennsylvania, United States Oak Street Health Full time
Job Title: Transitional Care Advanced Practice Provider

We are seeking a highly skilled and compassionate Transitional Care Advanced Practice Provider to join our team at Oak Street Health. As a key member of our care team, you will be responsible for delivering high-quality, patient-centered care to our most vulnerable patients in the comfort of their own homes.

Key Responsibilities:
  • Provide post-discharge support to patients in their homes, following established pathways and protocols.
  • Develop and implement individualized care plans, working closely with patients, families, and healthcare providers to ensure seamless transitions of care.
  • Optimize and monitor patients' clinical status, identifying and addressing gaps in care, and reconciling medications to prevent adverse events.
  • Collaborate with Transitional Care Managers, home health agencies, social workers, hospitals, and specialists to ensure comprehensive care coordination.
  • Structure and prioritize patient scheduling based on clinical complexity, ensuring timely and effective care delivery.
  • Recognize, diagnose, and manage acute and chronic medical conditions to prevent destabilization and readmissions.
  • Provide after-hours and weekend call support, working collaboratively with other in-state providers to ensure seamless coverage.
  • Facilitate and conduct goals of care and advance care planning discussions with patients and families, ensuring their values and preferences are respected.
  • Assess and evaluate family/caregiver needs and limitations, providing education and support to ensure optimal patient outcomes.
  • Teach patients, caregivers, and others about their health conditions, empowering them to take an active role in their care.
  • Accurately and timely document patient encounters in Oak Street Health's electronic medical record, ensuring seamless communication and care coordination.
  • Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting, to ensure a culture of safety and quality.
Requirements:
  • Active, non-probationary state medical license, including US work authorization, if applicable.
  • 1+ years APN experience, preferably with a Medicare population.
  • Experience in home-based care (as RN or APP) preferred.
  • Flexibility to travel throughout the service area.
  • Electronic Medical Record experience.
  • Computer skills: Ability to quickly navigate and use multiple computer programs, including Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
  • Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required.
What We Offer:
  • Mission-focused career impacting change and measurably improving health outcomes for Medicare patients.
  • Paid vacation, sick time, and investment/retirement 401K match options.
  • Health insurance, vision, and dental benefits.
  • Opportunities for leadership development and continuing education stipends.
  • New centers and flexible work environments.
  • Opportunities for high levels of responsibility and rapid advancement.

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.

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