Description
This role is a community-based, focusing on providing both urgent and primary care to our members where they live. Working in partnership with the member’s primary care provider and interdisciplinary team, the community-based NP is responsible for (1) seeing patients recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, (2) seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and (3) performing chronic disease management and preventive care in-conjunction with the center-based primary care team.Duties and Responsibilities Provide community-based medical and care-coordination services for recent hospital discharges Working closely with the transitional care manager and the member’s primary care team, following through on the discharge plan with the patient.
Conduct patient assessments
Review, monitor, adjust and discontinue medications
Comprehensive Medication Review for adherence
Patient and family education
Coordinate home care agencies and services
Develop and implement plan of care
Communicate patient’s medical, or mental conditions, substance abuse and social determinants of health needs
Document appropriately in the Electronic Medical Record
Gather critical information from member’s home environment and coordinates use of this information with healthcare team
Education & Experience Requirements Maryland licensed Nurse Practitioner with 2+ years’ experience
Extensive knowledge of local population, geography, and resources.
Excellent interpersonal and communications skills.
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.
Knowledge and experience 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
Preferred qualifications: Experience working with high risk and medically complex patients with multiple comorbidities preferred
Multiple settings experience (urgent care, ER, inpatient, office, or community based) preferred
Psychiatric and substance use disorder experience helpful
Employees are offered the following benefits: Free parking
Free Vision Plan
Medical and Dental plans
Life Insurance
Short Term Disability
401k Retirement plan
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