Home-Visit Primary Care NP for High-Risk Patients

AbsoluteCare; Washington (District of Columbia); Hybrid; USD 120,000 - 170,000; Full time

Job summary

AbsoluteCareis seeking a Community-Based Clinician to bring primary and urgent care into patients' homes, meeting members where they are and supporting them after hospital discharge. You will work alongside existing providers, coordinating with clinical teams and traveling to deliver care in the home and during transitions of care.

This role emphasizes social determinants of health, care coordination, and reducing readmissions, with strong EMR skills and a patient-centered approach.

Qualifications

• This is a Community Based position must be willing to do home visits.
• Certified Registered Advance Practice Provider in Adult Medicine with Acute Care experience.
• 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.
• Travel between Prince George County and Baltimore providing care to members in their homes.
• Coordinate 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 (ICT) members for problem solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs such as: abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
• 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

Travel to home visits

EMR proficiency

Microsoft Office basics

Patient-centered care

Education

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

ACLS certified

Job description

AbsoluteCareis seeking a Community-Based Clinician to bring primary and urgent care into patients' homes, meeting members where they are and supporting them after hospital discharge. You will work alongside existing providers, coordinating with clinical teams and traveling to deliver care in the home and during transitions of care.

This role emphasizes social determinants of health, care coordination, and reducing readmissions, with strong EMR skills and a patient-centered approach.