JOB SUMMARY:

Motivated and self-sufficient professional to work closely with the Medical Director of Population Health to address targeted care needs of patients assigned to Chase Brexton Health Care by the State of Maryland and others, including Accountable Care Organization and payor partners. A successful candidate will be highly committed to the organization's mission and values, will be a team player, and will possess the clinical skillset required to address a variety of value-based care priorities as defined within value-based care (VBC) contracts, including Entry to Care intake visits, Annual Wellness Visits, and hospital follow-up visits. The role will include providing clinical care services via a schedule of billable Telehealth visits and may include addressing cross-team administrative issues such as covering planned provider outages. The position will require close communication with scheduling teams to optimize continuity with new or existing primary care providers of the patients, as well as for care coordination purposes across multi-disciplinary teams (nursing, social work, pharmacy, behavioral health, substance use treatment, etc.). The successful candidate will be flexible and adaptable to different primary care provider styles, while ensuring alignment with VBC principles and targeted care measures, such as providing extended prescriptions and promoting adherence to chronic disease management plans. This position will not carry a panel and will be subject to unique productivity assessments. Evaluation of the role’s success will be determined by the supervisor (Medical Director of Population Health), with evolution of the role in response to organizational VBC contracts, in alignment with broader organizational priorities.

MAJOR DUTIES AND RESPONSIBILITIES:

PATIENT FOCUS

• Coordinates and ensures effective clinical appointment access and flow of care between departments and teams

• Effectively engages patients during Transitions of Care (including Entry to Care and post-hospital follow up)

• Assist patient to prioritize care needs that are “high-value”, i.e., USPSTF Grade A & B recommendations and others recommended for improving outcomes of chronic disease;

• Use healthcare data from the EMR, CRISP, local healthcare portal systems, to optimize use of healthcare resources and convene relevant specialty care recommendations with that of the primary medical home;

• Assist in identifying individuals and populations and connect to relevant resources to improve adherence, reduce utilization, and ensure optimal outcomes.

COMPLIANCE, POLICY, AND PROCEDURE

• Practices within established policy and protocol and effectively applies clinical judgement in alignment with standard clinical and practice guidelines, and in alignment with individual credentialing.

• Demonstrates independence and ability to locate policies and procedures that have been reviewed, for ongoing reference and use.

• Completes annual and periodic trainings and maintains competencies in alignment with professional licensing body.

ANALYTICAL AND CRITICAL THINKING

• Maintains the standard of clinical care, using diagnostic testing appropriately and cost effectively and providing appropriate treatment as applicable.

• Considers the psychosocial aspects of both health and disease.

• Work closely with primary care team to coordinate patient care needs and progress on established care plans;

• Review existing plans of care and follow through on those, and update as needed to align with the latest clinical guidelines, in partnership with patient and family preferences and needs;

• Contribute to patient risk stratification policies and systems;

• Optimize use of applications including the electronic medical record, the patient portal and external sources.

CHECKING, EXAMINING, AND RECORDING

• Maintains complete and comprehensive documentation of care provided, whether by audio or audio/visual telehealth visits.

• Timely completion of clinical documentation.

• Follow through on positive screening results.

• Addresses administrative coverage tasks within policy-defined timeframes.

PROFESSIONALISM:

• Demonstrates professional conduct, respectful communication, and adherence to attendance expectations.

• Demonstrates integrity in all aspects of patient care and related to use of organizational resources.

SKILLS AND ABILITIES:

• Ability to work within multi-disciplinary clinical team

• Demonstrated fluency with EMR and related systems to document clinical care delivery.

• Demonstrated fluency with Microsoft Office Suite (SharePoint, Outlook, Word, Excel)

• Ability to work effectively and respectfully in a multidisciplinary, culturally diverse team.

• Ability to build and maintain effective working relationships.

• Ability to coordinate, organize, and remain flexible.

EDUCATION AND/OR EXPERIENCE

• Required: Master’s degree from an accredited program in relevant clinical practice (NP/PA).

• Licensed nurse practitioner or physician assistant

• At least two years of clinical experience as an NP/PA or equivalent of two years of full-time practice (if position(s) were part-time).

• Appropriate Maryland licensure and clinical certification, DEA and Maryland CDS, X license interest in and/or experience in community health settings.

• Ability to work harmoniously with diverse groups of individuals.

• Excellent communication and team skills required.

• Preferred: Doctoral degree in nursing practice, primary care practice experience, telehealth experience, previous FQHC experience, MPH or other public health related degree and experience.

• Preferred: Experience with providing care to individuals living with HIV, transgender/non-binary individuals, immigrants with non-English as primary language, people in recovery, and other special populations.

• Preferred: demonstrated longevity in prior roles.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Remote position (with ability to attend on-site shadowing sessions, trainings, and events, as required);

• Home office space must ensure privacy and confidentiality of patient information.

• Must reside in Maryland;

• This role offers a high degree of critical thinking and autonomy, and is best filled by a “self-starter”;

• Ability to perform functions normally completed during the course of clinical care (i.e., sitting, standing, fine motor coordination), use of keyboard for typing or editing of EMR notes, clinically evaluating and communicating plans to patients, including via translation services as relevant.

• Travel among Chase Brexton sites may be required.