Advanced Practive Provider (APP), Nurse Practitioner (NP) or Physician Assistant (PA)

Reporting directly to the Medical Director, the APP is the clinical backbone of our California-based home delivery model. This role executes in-home Annual Wellness Visits (AWVs), manages complex clinical transitions of care (TOC) immediately following hospital discharge, and provides long-term stabilization for high-acuity patients enrolled in Complex Care Management (CCM) and is proficient at HCC coding and medical disease documentation. Provider should also be comfortable with acutely ill recently discharged patients being managed at home.

Essential Duties and Responsibilities

• In-Home Clinical Delivery: Conduct comprehensive, in-person clinical assessments in patients' homes or via telehealth across the specified California regional service area.
• Transitions of Care (TOC) Management: Conduct rapid post-discharge home visits (ideally within 48 to 72 hours of hospital or SNF release). Perform high-level medication reconciliation, identify early signs of clinical decompensation, and intervene to prevent 30-day readmissions.
• Complex Care Longitudinal Management: Manage a designated panel of high-acuity, frail, or dual-eligible beneficiaries. Develop, implement, and adjust individualized care plans in alignment with evidence-based protocols.
• Comprehensive AWV & Gap Closure: Perform Medicare Annual Wellness Visits in the home, completing detailed cognitive screenings, fall risk assessments, and personalized prevention plans while closing active quality care gaps and appropriately capturing HCC codes as part of documentation.
• Interdisciplinary Collaboration: Act as the primary clinical partner to the Care Navigation team. Participate in weekly interdisciplinary team (IDT) case conferences with the Medical Director, RNs, CHWs, social workers, and care coordinators.
• California Regulatory & Quality Compliance: Maintain accurate, timely EHR documentation utilizing appropriate HCC risk-adjustment coding guidelines. Ensure compliance with California practice acts, including maintaining standard written practice agreements or collaborative guidelines as legally required.

Minimum Qualifications

• Education: Master’s or Doctoral degree from an accredited Nurse Practitioner program OR graduation from an ARC-PA accredited Physician Assistant program.
• Licensure & Certification (California Specific): 
• Active, unrestricted California Registered Nurse (RN) and Nurse Practitioner (NP) license OR active California Physician Assistant (PA) license.
• National certification (AANP, ANCC, or NCCPA) in a relevant specialty (Adult-Gerontology Primary/Acute Care, Family Medicine, or Internal Medicine).
• Active California furnishing/prescribing authority and a valid DEA registration.
• Experience: Minimum of 2–3 years of clinical experience as an APP. Prior experience in home-based primary care, geriatrics, palliative care, or inpatient hospital medicine is highly preferred.
• Other Requirements: Must possess a valid California Driver’s License, a clean driving record, and a reliable, insured vehicle for daily travel to patient residences.

Work Environment

• Hybrid remote and in office in Los Angeles
• Patient home setting, up to 30%

Benefits: 

As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/why-cope-health-solutions/. 

About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com. 

To Apply: 

To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/.