The Role
As an In-Home Clinician (Nurse Practitioner or Physician Assistant), you will play a critical role in ensuring the health and well-being of our complex Medicare patients by conducting comprehensive in-home assessments, identifying healthcare needs, and coordinating complex care plans. You will collaborate closely with a multidisciplinary team to improve health outcomes and enhance the quality of life for our members. The position will also provide opportunities for advancement into clinical leadership roles based on performance and demonstrated leadership and management ability.
Responsibilities
- Conduct comprehensive in-home assessments for complex Medicare Advantage patients, including a thorough review of medical history, medication reconciliation, physical examination, and various health assessments (Social determinants of health, mental health, frailty, etc.).
- Identify and document healthcare needs, potential gaps in care, and risk factors through the assessment process.
- Develop personalized care interventions based on identified healthcare needs and coordinate with the patient's primary care provider and specialists as necessary.
- Educate patients and their caregivers on their healthcare conditions, medications, and self-management strategies.
- Collaborate closely with a multidisciplinary team, including registered nurses, social workers, primary care providers, and specialty providers, to ensure comprehensive care coordination.
- Provide support and guidance to patients and their families to promote better health outcomes and quality of life.
- Maintain accurate and up-to-date documentation of assessments, clinical encounters, quality measures, and patient interactions in accordance with Medicare and Medicaid regulatory standards.
Requirements
- Current Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of New York.
- Provider enrollment with Medicare and New York state Medicaid.
- Minimum of 3 years of clinical experience as an advanced practice provider in a field-based clinical role, preferably in primary care, geriatrics, or a similar field.
- Experience with Medicare Advantage programs and familiarity with CMS guidelines and regulations is a plus.
- Strong interpersonal and communication skills to effectively engage with patients, families, and a diverse healthcare team.
- Ability to work independently, prioritize tasks, and manage time effectively.
- Ability to drive up to 2 hours distance to conduct in-home visits.
- Cities covered: Yonkers, Westchester, and Poughkeepsie.