Advanced Practice Provider - Chronic Care Coordination

AbsoluteCARE Medical Center & Pharmacy; Baltimore, Northern (MD, KY); Hybrid; USD 90,000 - 135,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy seeks a Complex Care Advanced Practice Provider to lead outpatient chronic care management within the PCMH model. You will assess patients, guide care settings, and collaborate with a large care team to deliver whole-person care.

You will manage a panel of patients with multiple chronic conditions, coordinate transitions from hospital to home, and educate patients on disease management and advance directives, reporting to the Medical Director.

Qualifications

• Licensed Advanced Practice Provider in the state of practice.
• Minimum 2 years of Advanced Practice Provider experience.
• ACLS certification.
• Proficiency with EMR, eClinicalWorks preferred.

Responsibilities

• Counsel patients on setting appropriate care, perform assessments.
• Manage a panel of 250–300 chronic ambulatory patients.
• Collaborate with an interdisciplinary team (social work, case management, behavioral health, pharmacy, nutrition).
• Develop transitional care plans from hospital to home, tracking paneled patients.
• Educate patients on chronic diseases and advance directives.
• Report to the Medical Director.

Skills

Advanced Practice Provider

Chronic disease management

Outpatient care

Interdisciplinary team collaboration

EMR proficiency

Education

Licensed Advanced Practice Provider (state license)

ACLS certification

2+ years Advanced Practice Provider experience

Tools

eClinicalWorks

Job description

AbsoluteCARE Medical Center & Pharmacy seeks a Complex Care Advanced Practice Provider to lead outpatient chronic care management within the PCMH model. You will assess patients, guide care settings, and collaborate with a large care team to deliver whole-person care.

You will manage a panel of patients with multiple chronic conditions, coordinate transitions from hospital to home, and educate patients on disease management and advance directives, reporting to the Medical Director.