Home-Based NP - Transitional Care Specialist

AbsoluteCARE Medical Center & Pharmacy; Greenbelt (MD); On-site; USD 110,000 - 140,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy in Maryland is seeking a Community Based Clinician (Nurse Practitioner) to provide primary and urgent care in patients' homes, focusing on transitions of care after discharge and collaboration with the care team.

The role requires ACLS, CRNP in Adult Medicine with Acute Care experience, strong EMR skills, and the ability to educate patients, coordinate with the care team, and manage a small homebound panel to prevent readmissions.

Qualifications

• This is a Community Based position must be willing to do home visits.
• ACLS certified.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
• Ability to meet deadlines and manage multiple priorities.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions.

Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges.
• Manage a small panel of homebound members who require primary care.
• Resolve acute issue in the home and clinic or by directing member to most effective and efficient solutions.
• Timely and accurate completion of chart documents.
• Work with Treatment and Triage Nurse to address sick calls and visits requiring Provider management.
• Receive input from the Core Clinical Team to define visit goals.
• Communicate important post visit follow up information to Core Clinical Team.
• Collaborate with Integrated Care Team for problem solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs.
• Implement transitional care protocols as part of warm hand offs between internal and external care providers.
• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
• Adjust care plan following guidelines for evidenced based chronic disease management.
• 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.

Skills

Home visits

EMR proficiency

Care team coordination

Problem solving

Education

Certified Registered Advanced Practice Provider in Adult Medicine with Acute Care experience

Tools

Microsoft Office

Job description

AbsoluteCARE Medical Center & Pharmacy in Maryland is seeking a Community Based Clinician (Nurse Practitioner) to provide primary and urgent care in patients' homes, focusing on transitions of care after discharge and collaboration with the care team.

The role requires ACLS, CRNP in Adult Medicine with Acute Care experience, strong EMR skills, and the ability to educate patients, coordinate with the care team, and manage a small homebound panel to prevent readmissions.