Comprehensive Care Advanced Care Practitioner - Tucson, AZ

Direct Hire | $130K-$150K Annually, DOE

***Traveling required***

Job Summary:

The Comprehensive ACP, reporting to the Market Medical Director, will be an integral part of the clinical team. The Comprehensive ACP is responsible for seeing our highest priority members either in-center or through the Doxy.me telehealth platform and closing all remaining care gaps for the calendar year in a single visit.

Essential Duties/Responsibilities:

• Conduct Prospective Chart Prep for clinical diagnostic and quality opportunities of identified members sufficiently in advance of member visits to ensure there is a plan to comprehensively address open care gaps for every member encounter.
• Engage with center leadership and care team members to ensure members are prioritized for scheduling based on outstanding care gaps and maintain a target schedule template fill rate of 75%.
• Complete encounters with identified members in-center or using the clinics approved telehealth platform(s).
• Address all historical and suspected conditions presented via point of care interface (VIM).
• Address all open HEDIS measures of Focus On Care (FOC).
• Interpret evidence-based practice screenings including point of care testing.
• Formulate a list of current medical conditions using clinical knowledge and judgment.
• Document an assessment and plan for all chronic conditions in the EMR to align with the PCP treatment plans.
• Coordinate appropriate follow up care and maintain effective communication with the member’s assigned care team to facilitate effective continuity of care.
• Identify urgent and emergent situations and intervene appropriately.
• Educate members on topics such as disease process, preventative screening schedule, and medication adherence.
• Maintain a high level of engagement and attend all training sessions and center meetings; demonstrate strong proficiencies with Clinical Documentation Improvement (“CDI”) education; and assist other providers to understand CDI concepts.
• Perform at above-average member experience metrics.

Required Education and Experience: 

• Active NP or PA license or ability to obtain by start date. Licensure must be unencumbered, free of any open/unresolved disciplinary actions including probation or restrictions against privilege to practice.
• Active ANCC, AANP, or PA national certification in Family, Geriatrics, Adult, Adult-Gerontology Primary Care, or Adult-Gerontology Acute Care certification
• Ability to complete physical requirements of the job including lifting a 30-pound bag in and out of the car, navigating stairs and a variety of dwelling conditions, and sit, stand, and kneel to perform physical assessment.
• 1 years of clinical experience in their highest level of education, clinical setting
• Experience in gerontology, cardiology, internal medicine, or endocrinology
• Ability to travel within license state if requested for additional incentives (with notice, based on business needs)

Knowledge, Skills, and Abilities:

• Experience with Electronic Medical Records
• Advanced knowledge of ICD-10 diagnosis codes
• Advanced knowledge of diagnostic criteria
• Medicare Advantage experience including knowledge of the HCC model and STARs measures
• Ability to create, plan, implement and evaluate patient specific care plans
• Ability to exercise use of independent judgement
• Sensitivity to the diverse needs of culturally diverse staff, patients, and communities
• Master's Degree in Nursing. Active ANCC, AANP, or PA national certification in Family, Geriatrics, Adult, Adult-Gerontology Primary Care, or Adult-Gerontology Acute Care certification
• Licensure must be unencumbered, free of any open/unresolved disciplinary actions including probation or restrictions against privilege to practice.

* Develop treatment plans, based on scientific rationale, standards of care, and professional practice guidelines.

* Recommend diagnostic or therapeutic interventions with attention to safety, cost, invasiveness, simplicity, acceptability, adherence, and efficacy.

* Counsel patients about drug regimens and possible side effects or interactions with other substances, such as food supplements, over-the-counter (OTC) medications, or herbal remedies.

* Educate patients about self-management of acute or chronic illnesses, tailoring instructions to patients' individual circumstances.

* Keep abreast of regulatory processes and payer systems, such as Medicare, Medicaid, managed care, and private sources.

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