Nurse Practitioner

ChenMed LLC; Roselawn (IN); On-site; USD 180,000 - 240,000; Full time

Job summary

ChenMed, a physician-led and mission-driven primary care organization, is expanding and seeks a Lead PCP to deliver accountable, outcome-focused care for a panel of patients. The Lead PCP will coach patients toward achievable health goals, lead a care team, and help maintain a culture of love, accountability, and excellence across centers.

This role requires independent practice, collaboration with hospitalists, and participation in risk and quality management programs to meet clinical and

Responsibilities

• Independently provides care for patients in older adult population.
• Takes full accountability for patient care and outcomes and seeks consultation from specialists when needed.
• Engages with hospitalists whenever a patient is in the hospital.
• Responsible for assessment, diagnosis, treatment, management, education, health promotion and care coordination.
• Leads their care team including medical assistant, care facilitator, and care coordinator.
• Coordinates with transitional care and other resources for patients unable to come to the office.
• Leads weekly SH/Transforming Care Meeting and supports center leadership as needed.

Job description

We’re unique. You should be, too. We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

POSITION SUMMARY

ChenMed, a physician-led and mission-driven, primary care organization, is currently one of the most successful full-risk Medicare Advantage providers in the nation and has a vision to be America’s leading primary care provider, transforming care of the neediest population. Our mission is to honor seniors with affordable VIP care that delivers better health. In order to achieve our vision and deliver our mission, we need the best primary care providers and clinical leaders that are seeking to fulfill purpose and personal opportunity and join the ChenMed family.

• Accountability for outcomes: The Lead PCP demonstrates accountability for outcomes, strong clinical care, and cost-effectiveness for each patient in their panel of at least 360 patients. They understand that they can strongly influence the patient’s outcomes by building a trusting relationship and helping them change behaviors.
• Coaching for health: The Lead PCP acts as a health coach, rather than just a consultant for sickness, by helping patients set short and long-term health goals, partners with the patient to work toward the goals, and frequently follows up on those goals on the path to improved health for their patients.
• Simplifying for action: The Lead PCP simplifies and prioritizes appropriately so that behavior change is more actionable, both for the patient in helping them achieve their goals, and when leading their care teams towards their performance goals.
• Leadership: Leads Super Huddle (SH) and Transforming Care Meeting (TCM) weekly, as well as supports Center Manager/Center General Manager if the center clinical leader and/or market clinical leader is not available. The Lead PCP will fill in as needed for center clinical leadership needs, including monitoring daily center census as part of joint center accountability for outcomes. Drive a positive culture that supports a cohesive team approach, drives excellent results and relationships, and promotes "best place to work" culture measured by employee engagement scores.

We are an outcomes-focused, value-based organization and for their panel of patients, the following metrics are regularly measured to help Lead PCPs become successful and become successful PCP Partners: patient admissions/thousand, 16-18 appointment slots per day at a 0.9 FTE PCP schedule / 0.1 FTE dedicated leadership time (each new patient count for 2 slots, follow-up patients, typical 1.0 PCP FTE slots are 18-21), HEDIS>4, CG CAHPS (patient experience), clinical gaps closures, and medical cost effectiveness relative to center target.

Each Lead PCP will have goals for these metrics and will be expected to work towards those targets with their center and market leadership as well as their care teams.

Culture is very important in the medical centers and because PCP’s are leaders in our organization and centers, they are expected to help champion a positive culture of love, accountability, and passion along with center leadership.

The Lead PCP will be required to demonstrate the ability to function both independently and in collaboration with other health care professionals.

The Lead PCP will work closely with the applicable center and market leadership to ensure compliance with guidelines along with participating in risk and quality management programs, clinical meetings and other meetings as required that promote patient health and company goals.

The Lead PCP will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES

Independently provides care for patients with acute and chronic illnesses encountered in the older adult patient.

Takes full accountability for patient care and outcomes and appropriately seeks consultation from specialists when needed, though will still stay involved in, and be responsible for, the detailed care of the patient.

Engages with the hospitalist whenever one of their patients is in the hospital (regardless of whether the hospitalist works for ChenMed or not).

Responsible for assessment, diagnosis, treatment, management, education, health promotion and care coordination and documentation for patients with acute and complex chronic health needs.

Leads their care team consisting of care promoter (medical assistant), care facilitator, and care coordinator for patients able to come to the office.

For patients that are unable to come to the office—in hospital, SNF, LTC or homebound, engages with the transitional care team and others including case managers, acute and transitional-care physicians, and other resources that may be available depending on the market.

Leads Super Huddle (SH)