Complex Care APP: Chronic Disease Focus

AbsoluteCare; Washington; On-site; USD 110,000 - 170,000; Full time

Job summary

AbsoluteCare seeks a Complex Care Advanced Practice Provider for our outpatient team. You will counsel patients on care settings, assess problems, and guide them through evidence-based PCMH care within a large integrated system.

You will manage patients with multiple chronic conditions, collaborate with social work, case management, behavioral health, pharmacy, nutrition, and others, and develop transition plans across hospital, ER, SNF, and home care.

Qualifications

• Licensed Advanced Practice Provider in the state of practice.
• ACLS certification.
• Minimum of 2 years experience as an Advance Practice Provider.
• Experience with Medicare, Medicaid, and commercial populations.
• Knowledge of chronic disease management programs and services.
• Excellent organization and communication skills.
• Comfortable treating acutely ill in outpatient settings with supervision.

Responsibilities

• Manage and improve health for patients with multiple chronic medical conditions.
• Work in a team environment with social work, case management, behavioral health, pharmacy, nutrition, etc.
• Develop strong transitional care plans and track paneled patients along the continuum of care.
• Facilitate appropriate discharge to lower or higher levels of care with supervising physician.
• Accept same day/next day or urgent appointments for discharged patients to ensure resolution.
• Track patients to prevent ER visits, hospital admissions, and readmissions.
• Educate patients regarding chronic diseases and advanced directives.
• Practice evidence-based medicine per PCMH model of care.
• Participate in multi-disciplinary meetings and recommend treatment alternatives.
• Report to the Medical Director.

Skills

Chronic disease management

Care coordination

Team-based care

Patient education

Excellent communication

EMR proficiency

Education

Licensed Advanced Practice Provider

ACLS certification

Minimum 2 years APR experience

Experience with Medicare/Medicaid and commercial populations

EMR knowledge

Tools

eClinicalWorks

Job description

AbsoluteCare seeks a Complex Care Advanced Practice Provider for our outpatient team. You will counsel patients on care settings, assess problems, and guide them through evidence-based PCMH care within a large integrated system.

You will manage patients with multiple chronic conditions, collaborate with social work, case management, behavioral health, pharmacy, nutrition, and others, and develop transition plans across hospital, ER, SNF, and home care.