Advance Practice Practitioner

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

The Grace at Home program is designed to provide additional support to our patients by providing an integrated level of equitable value-based medical care and social support in the comfort of where our members call home. This program is offered to eligible health plan patients with the primary goal of mitigating adverse health complications, unmanaged disease progression and ultimately avoid unnecessary hospitalization that can occur when timely clinical interventions are not provided or are not accessible.

In this role, you'll collaborate closely with a multi-disciplinary clinical team to deliver high-quality, personalized care in both a home-based and telehealth setting. The ideal candidate is committed to providing longitudinal care to build meaningful patient relationships, improving patient outcomes, and eager to make a meaningful impact in underserved communities.

Responsibilities

• The Advanced Practice Provider will conduct comprehensive and follow-up patient assessments via a combination of in-home and virtual telehealth visits to include, but not limited to, Annual Wellness Visits (AWV) and Health Risk Assessments (HRA) in accordance with established guidelines set forth by Medicare, Medicaid, and commercial marketplace healthcare plans we serve.
• Commit to the practice of value-based care which emphasizes care in a home-based setting to improve and lower healthcare related costs, address and close gaps associated with population health leadership and drive high patient satisfaction.
• Conduct continued follow-up care of members to identify acute and chronic care diagnoses to be assessed in care management and active medical management.
• Works collaboratively with multi-disciplinary team members to develop and implement personalized treatment plans, including prescribing medications, therapies, and lifestyle modifications to promote a patient-centric care model.
• Deliver exemplary bedside manner with the ability to communicate complex medical information with simplicity and kindness to our members. Work in partnership with patients in the prevention of illness, promotion of health, and management of patient's adjustment to chronic health problems.
• Potential for on-call back up support for nurse line in licensed states.
• Demonstrate proficiency and support use of the practice management system and electronic medical record (EMR).
• Abide by the ethics of the nursing/medical profession and all pertinent federal and state regulations and ordinances applicable to an individual’s scope of practice, including established HIPAA guidelines.
• Stay current with medical advancements, evidence-based practices, and professional development activities.
• Contribute to quality improvement initiatives, research projects, and educational programs as required.
• Other duties as assigned by the Clinical Operations Director and Supervising Physician

Qualifications

• Current, unrestricted NP or PA license to practice in state.
• Willingness to obtain additional state licenses as needed for virtual coverage.
• Family Nurse Practitioner degree with ability to treat throughout lifespan.
• Graduate of an accredited Nurse Practitioner program required.
• Board Certification from ANCC or AANP (Nurse Practitioner)
• Prescriptive authority/authorization in the State of state including the ability to obtain DEA controlled substance registration.
• Valid NPI and American Heart Association BLS Certification
• Proven clinical experience as an Advanced Practice Provider, preferably in primary care, hospice, or urgent care/outpatient setting.
• Current state drivers' license, auto insurance and reliable transportation
• Excellent administrative, organizational, and communication skills required
• Commitment to ongoing professional development and staying abreast of the latest medical advancements.
• Compassionate and caring attitude with a desire to live our mission, vision and values.

Preferred Qualifications

• Knowledge of HCC documentation, ICD-10 Coding, Health Risk Assessments, HEDIS, and STAR quality measures.
• Bilingual proficiency in applicable areas.
• Experience in care of entire lifespan (pediatrics through geriatrics) preferred.
• Previous Medent EHR experience preferred

The working environment and physical requirements of the job include:

• This position requires in-home, assisted living, and independent-living community-based work.
• The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.
• In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting or standing for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 50 lbs. occasionally may be required. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.