KEY RESPONSIBILITIES:

1. Proven ability to perform comprehensive, adult/geriatric physical exam

2. Demonstrates ability to identify, diagnose and document chronic disease in adults

3. Demonstrates ability to recognize conditions, characteristics, and behaviors that place seniors at risk

4. Proven ability to pursue feedback, continuing education and professional development

5. Ability to effectively reconcile medications

6. Demonstrates ability to identify and document the needs of clinically complex patients

7. Work collaboratively with physicians, case managers, social workers, family members, key care givers and any appropriate ancillary medical personnel as appropriate

8. Participates in and/or directs Quality Assurance Performance Improvement (QAPI) activities

9. Understands the PruittHealth Premier Plan benefits, PruittHealth Premier Plan policies, procedures and articulate them effectively to providers, members and key decision-makers

10. Assesses the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team members

11. Coordinates care as member's transition through different levels of care and care settings, ensures that the ICP is communicated immediately and/or no later than 24 hours to the receiving care setting

KNOWLEDGE, SKILLS, ABILITIES

1. Pertinent Clinical Work Experience which is relevant to population being served.

3. Interprets laboratory data, recommend appropriate follow-up, reconcile medications

4. Manages both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider

5. Synthesizes information and easily diagnoses and creates a comprehensive plan of care.

6. Ensures that individual plan of care is developed with specific interventions designed to meet the needs identified in the Health Risk Assessment

7. Performs comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations

8. Performs Health Risk Assessment within seven (7) days of enrollment for a new beneficiary and annually within one year of the initial assessment.

9. Conducts an annual Comprehensive Geriatric Exam that incorporates CMS Annual a WellnessVisit

elements, including the Personalized Prevention Plan Services (PPPS)

10. Ensures all diagnoses are ICD-10 coded accurately and documented appropriately to support the diagnosis at that visit

11. Conducts HRA comprehensive face-to-face assessment if the member experiences a change in condition and/or transition in care—a “trigger” event.

12. Reviews orders and interventions for appropriateness and response to treatment to identify most effective plan of care that aligns with the member's needs and wishes

13. Evaluates plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations

14. May be required to participate in on-call program, after hour or coverage may be required

15. Rotating on call responsibilities

16. Travels between care sites mandatory

17. Performs other duties as assigned

Family Makes Us Stronger. Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference.

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As a condition of employment at PruittHealth, all employees are required to provide proof of COVID-19 vaccination by date of hire unless a medical or religious exemption is approved.

As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.