Family Practice/Primary Care Nurse Practitioner

The Community-Based Provider (CBP) sees patients in their home. The CBP primarily does in-home medical assessments, and ensures they are engaged in active primary care. This position adds to a member s current care, collaborating with their current care providers. The role is immensely satisfying, as you develop a deep understanding of our patients needs, and are able to engage a robust care team to address them. Seeing members in the home allows you great insight into the social factors that affect their care. This is a tremendous opportunity to impact the care of vulnerable patients.

This position is paid per completed visit. It enables providers to have a flexible work schedule.

Duties and Responsibilities

Provide community-based medical care and care-coordination:

• In-Home Assessments (IHA): Conduct comprehensive in-home assessments for patients, including medical history reviews, physical examinations, and medication management.

• Patient Assessment: Conduct thorough assessments of patients' health status, including physical examinations, medical histories, and risk assessments.

• Work collaboratively with physicians, case managers, social workers, family members, key caregivers and any appropriate ancillary medical personnel as appropriate

• Collaborate with Primary Care Physician (PCP) on patient education, provide follow-up

• Provide services in a variety of venues to include: Home Visits, Skilled Facility Visits, and Telehealth Visits

• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.

• Educate and coach for medication adherence and chronic disease self-management skill development.

• Monitor members at risk of being lost to care and implement interventions to prevent loss.