Salary Range: $90,000 to $115,000
Description of Duties
The Advanced Practice Clinician, Care Partner (Mobile) will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life/palliative care. The role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member-centric individualized care plan along with the authorization of appropriate durable medical equipment and services.
This position covers the northern territories: Greenfield, Bondsville, Miller's Falls, Turner's Falls, etc.
- Facilitate, and/or deliver preventative care to members.
- Drive to member's homes to provide regularly scheduled follow up visits for the management of chronic disease or end of life/palliative care.
- Perform episodic urgent medical/ behavioral health visits to ensure that panel members are given timely and appropriate medical care in order to avoid emergency room or hospitalization.
- In order to decrease the risk of readmission, perform post-discharge visits on panel members within 48-hours of discharge from either an acute care facility or a skilled nursing facility;
- Provide Intermittent Skilled Care as necessary (e.g., wound care,)
- Develop a member-centric care plan which is inclusive of appropriate long-term support services and optimizes available resources to improve or maintain health and functional independence in the community.
- Conduct annual/6-month MDS assessments and annual comprehensive assessments for panel members based on the program.
- Act as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members.
- Provide consultation and support to other members of the Care Team.
- Home Care
- Primary Care
- Bilingual in Spanish and English
- Relocation: None
- Reports To: Team Lead
- Remote Work: Up to 100% of the time
- Travel: Up to 100% of the time
- Visa: Applicant must be a U.S. citizen or a current Green Card holder