Advanced Practice Clinician (NP, PA) - Home Based, Waterbury, CT 06701

Company: Avidity Exchange
Location: Bridgeport
Posted on: April 6, 2021

Job Description:

Advanced Practice Clinician (NP, PA) - Home Based Nurse: Advanced Practice Nurse: Home Health Waterbury, CT 06701 Full-time licenses and certifications BLS, DEA, Driver's License, NC License, PA-C , AANP care settings Home Health Job Title Advanced Practice Clinician (NP, PA) - Home Based Care Job Description In this role, you will provide direct services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. You will a mobile care provider, extending out in the surrounding neighborhood and community. It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will frequently take you out into the field and surrounding community to provide care in settings that work best for our members. As an Advanced Practice Clinician, you will work with a panel of members to improve their health holistically through longitudinal primary care, care management, and care coordination. You will provide a necessary bridge to specialty care, homecare services, and other facility services. You will provide comprehensive care management, chronic disease management, urgent community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care. Additionally, you will provide clinical support to our team of Community Health Partners, who will serve as members main point-of-contact and coordinator. You will work alongside, and will be supported by, a care team associated with each member, whose work is focused around a Member Action Plan (MAP). Required Skills and Experience - NP or PA with licensure in good standing in Connecticut - AANC or AANP certification for NPs - Connecticut Controlled Substance Registration - DEA Controlled Substances Registration - Certified in Basic Life Support for Healthcare Providers - Experience providing clinical services to individuals with co-occurring chronic medical and behavioral health conditions, and have an interest in serving complex, vulnerable, and disabled populations. - Proven skills, knowledge base, and judgment necessary for independent clinical decision-making. - Organized, efficient, independent self-starter and problem-solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of whole community health. - Excited about how technology can support your work and help drive the ongoing evaluation toward new and better care. - Experience caring for seniors in a low-income community or in a community health setting. - Experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff. - Unrestricted Connecticut Drivers License and vehicle for daily usage - Bilingual and bicultural What You Need to Know - Follow a panel of members for primary care, and provide clinical support to the interdisciplinary care teams. - Interface with specialists, hospitals, and community based organizations to promote an understanding of the organization's model, facilitate collaboration, and promote shared decision making. - Perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization. - Perform post-discharge visits for members who have been recently discharged from either an acute care facility or skilled nursing facility to decrease risk of readmission; perform detailed medication reconciliation, and assure that appropriate long term services are in place. - Monitor and address clinical quality gaps in care. - Participate equally in all call responsibilities. - Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, members, and family. This platform is being built for a mobile workforce, and you will use our technology in the field, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others. - Attends external meetings and activities, and maintains professional credentialing and CME standards. perks Professional development opportunities Full benefits 401k The role: In this role, you will provide direct services to members, who face economic and social challenges in addition to having mental and physical health needs, through our innovative care model. You will be a mobile care provider, extending out in the surrounding neighborhood and community. It is integral to our care model that we meet people where they are, both physically and emotionally. Given this, your work will frequently take you out into the field and surrounding community to provide care in settings that work best for our members. As an Advanced Practice Clinician, you will work with a panel of members to improve their health holistically through longitudinal primary care, care management, and care coordination. You will provide a necessary bridge to specialty care, homecare services, and other faility services. You will provide comprehensive care management, chronic disease management, urgent community-based primary care visits, preventative care and wellness, liaison with relevant other providers around behavioral health and long term service and support needs, and the provision of palliative care. Additionally, you will provide clinical support to our team of Community Health Partners, who will serve as members main point-of-contact and coordinator. You will work alongside, and will be supported by, a care team associated with each member, whose work is focused around a Member Action Plan (MAP). You will: - Follow a panel of members for primary care, and provide clinical support to the interdisciplinary care teams. - Interface with specialists, hospitals, and community based organizations to promote an understanding of clients model, facilitate collaboration, and promote shared decision making. - Perform episodic urgent medical/behavioral health visits and/or telephone calls for members on your panel to ensure that timely and appropriate medical care in order to avoid emergency department visit or hospitalization. - Perform post-discharge visits for members who have been recently discharged from either an acute care facility or skilled nursing facility to decrease risk of readmission; perform detailed medication reconciliation, and assure that appropriate long term services are in place. - Foster lasting and trusting relationships to assist members in achieving goals, identifying new needs, and coordinating care. - Monitor and address clinical quality gaps in care. - Participate equally in all call responsibilities. - Go above and beyond to connect with members and partners in a non-judgmental, respectful and empathic manner, to meet their needs, and to provide feedback to the system as a whole as we strive to do better every day. - Work daily within our custom-built care facilitation platform, which will enable you to collect data, organize information, track tasks, and communicate with staff, members, and family. This platform is being built for a mobile workforce, and you will use our technology in the field, provide feedback to the product development team, and, over time, become part of a super-user group to assist in onboarding and supporting others. - Attends external meetings and activities, and maintains professional credentialing and CME standards. - Act as a mentor to other team members to help promote accountability, reliability, and independence among the other team members. Offer teaching opportunities and in-services as able. - Assists management and leadership with the development, refinement, and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects. Youd be a good fit if: - You have an NP or PA with licensure in good standing in Connecticut - AANC or AANP certification for NPs - Connecticut Controlled Substance Registration - DEA Controlled Substances Registration - Certified in Basic Life Support for Healthcare Providers - You have experience providing clinical services to individuals with co-occurring chronic medical and behavioral health conditions, and have an interest in serving complex, vulnerable, and disabled populations. - Proven skills, knowledge base, and judgment necessary for independent clinical decision-making. - You are an organized, efficient, independent self-starter and problem-solver, a leader, a strategic thinker, and a mentor, who is excited about the big picture of whole community health. - You are excited about how technology can support your work and help drive the ongoing evaluation toward new and better care. - You have experience caring for seniors in a low-income community or in a community health setting. - You have experience working collaboratively with an interdisciplinary care team, and specifically working alongside community health workers or care coordination staff. - Unrestricted Connecticut Drivers License and vehicle for daily usage - Bilingual and bicultural

Keywords: Avidity Exchange, Bridgeport , Advanced Practice Clinician (NP, PA) - Home Based, Waterbury, CT 06701, Other , Bridgeport, Connecticut