(Archived) Nurse Practitioner - Field Based

About the Role:

 You will work in a radically different model of healthcare

 Expect collaboration, shared-decision making, and partnership across clinical and

non-clinical care team members, including our team of Virtual Community Health Partners

 You can expect to complete annual provider visits for client members

 You will care for a population of Medicare Advantage members

 Your work will be primarily field-based, and you will meet members in their homes in their community in Western and Central Connecticut

 While a field-based, in-person team member, you will work within the virtual integrated care model

 You will partner closely with our team members in our Virtual Hub - including Virtual Community Health Partners, who are remote - to support your member

population

 You will report through the Virtual Hub to our Virtual Medical Director

 You will schedule your own annual provider visits and partner with our Member Advocates should you need support

 During the annual provider visits you will: address: member concerns, chronic medical conditions, clinical quality gaps in care and code for all relevant medical conditions

 Utilize our custom-built care facilitation platform, Commons, and the market’s EMR to collect data, document member interactions in the field, organize information, track tasks, and communicate with your team, members, and community resources

 Assist management and leadership with the development, refinement, and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects

 Attend daily team huddles and weekly case conferences to advise on physical health needs and establish health goals as part of members’ Member Action Plan (MAP)

Requirements for the Role:

 You are a Board-Certified Nurse Practitioner with an unrestricted license to practice in CT

 AANC or AANP certification for Nurse Practitioners

 Active DEA Controlled Substance Registration or eligible for application

 Certified in Basic Life Support for Healthcare Providers

 Maintenance of professional credentialing and CME standards

 Work a full-time 40 hour week. There is some flexibility on days/week that you will work

 You will attend and be an active member of collaborative, interdisciplinary team meetings on a daily basis including, team meetings and case conference

 You have experience providing annual provider visits to individuals with both chronic medical and behavioral health conditions, and have interest in serving complex, vulnerable, and disabled populations

 Demonstrate proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture &

phlebotomy), assessment and care plan reinforcement for common chronic conditions such as diabetes, hypertension, CHF, depression.

 Proven skills, knowledge base, and judgment necessary for independent clinical decision-making

 You are an adaptable organized, efficient, independent self-starter and problem-solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of whole community health

 You are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care

 You have an unrestricted driver’s license and vehicle for daily use

How We Define Success:

 Contribute to the management of complex population of members in collaboration with an interdisciplinary team [you will join case conference and suggest follow-ups

to the team]

 Decrease unnecessary hospitalizations, emergency room visits, and unnecessary speciality referrals

 Complete comprehensive provider visits with new assigned members. Identify core member needs the team will address to improve health

outcomes and decrease total cost of care

 Meet evolving monthly and quarterly targets for visits with members, in both clinic and home setting

 Engage in target setting for new clinical initiatives and managing those targets

Nice to Have, But Not Required:

 You have experience caring for members in a low-income community or in a community health setting

 You have experience with Hierarchical Condition Category Coding (HCC)

 You have experience with Geriatrics, Family Medicine, or Palliative care

 You have experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff

 Multilingual