Part Time Community Based Nurse Practitioner Greenbelt

AbsoluteCare; Greenbelt (MD); On-site; USD 110,000 - 160,000; Full time

Job summary

AbsoluteCare in Maryland is seeking a Community-based Clinician to provide primary and urgent care in the home, with a strong focus on transitions of care after hospital discharge. You will collaborate with the patient’s PCP, care manager, and the Integrated Care Team to coordinate visits and resources, ensuring timely follow-up and smooth handoffs.

You will manage a small panel of homebound members, address acute issues in the home or clinic, educate patients on chronic disease self-management

Qualifications

• This is a Community Based position; willing to do home visits.
• ACLS certified.
• Ability to meet deadlines and manage multiple priorities.
• Experience using EMR and data reporting.
• Patient-centered focus and problem-solving skills.
• Familiar with care transitions and reducing readmissions.

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 issues in the home and clinic or direct patients to the most effective solutions.
• Coordinate with PCP, care manager, and social workers to define visit goals.
• Communicate important post-visit follow-up information to the core clinical team.
• Collaborate with Integrated Care Team (ICT) members for problem solving and coordination of care.
• Identify referrals to specialty programs during instability or crisis.
• Implement transitional care protocols during warm handoffs between internal and external care providers.
• Educate and coach for medication adherence and chronic disease self-management.
• Monitor members at risk of loss to care and intervene to prevent loss.

Skills

Care coordination

Patient-centered care

Time management

Problem-solving

Adaptability

Education

Certified Registered Nurse Practitioner - Adult Medicine

ACLS certified

Tools

Electronic Medical Records (EMR)

Microsoft Office

Job description

The Community-based Clinician provides needed primary and urgent care in the home. Great focus on managing transitions of care, especially in the important and delicate time after hospital discharge. This position adds to a member’s current care, collaborating with their current care providers. The role is immensely satisfying, as you practice enhanced primary care and have the benefit of expert care management. Seeing members in the home allows you great insight into the social factors that affect their care. This is a tremendous opportunity to impact the care of vulnerable patients.

Duties And 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.

• Acute onset of a new illness.
• Evaluation of acute exacerbations of chronic conditions.
• Shortness of breath without chest pain, change in mental status or new onset hypoxia.
• CHF exacerbations
• Asthma/COPD exacerbations
• Bronchitis/pneumonia
• Hyperglycemia
• Elevated blood pressure
• Evaluation and treatment of a variety of infections
• New or worsening aches or pains, wounds, depression and/or anxiety.
• Members we know will go to the ER if not seen today.

Ensure Coordination Of Care To Include

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 (PCP, Care Manager or SW) to define visit goals.
• Communicate important post visit follow up information to Core Clinical Team.
• Collaborate with Integrated Care Team (ICT) members (behavioral health, nutrition, health education) 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.

Education & Experience Requirements

• This is a Community Based position must be willing to do home visits
• Certified Registered Advance Practice Provider in a field of 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.

Preferred Qualifications

• Experience in a Patient Center Medical Home.
• Experience working with high risk and medically complex patients with multiple comorbidities.