Ensures a defined panel of members receive the highest quality primary care within the context of a member centric plan of care, improving outcomes by impacting acute care utilization & ensuring optimal treatment for chronic disease management, in collaboration with the member’s network PCP, providers & specialists. Performs in-person home visits to medically complex members to decrease acute care utilization & improve member health & well-being

Essential Responsibilities:

• Performs urgent, routine, & post hospital visits on complex medical & psychiatric members.
• Orders medical testing to aid in diagnosis & medical management of acute & chronic diseases.
• Evaluates test results, treats member illness & communicates/collaborates on plan with PCP.
• Prescribes & bridge-prescribes medications based on medical evaluation for acute & chronic conditions independently & in collaboration with PCP/Medical Director.
• Monitors response to action & treatment plans.
• Assists with Advanced Care Planning; establishing goals of care, & obtaining HCP & MOLST forms.
• Provides limited regularly scheduled follow-up visits for management of chronic disease.
• Visits inclusive of history of present illness, systems review, physical exam, medication reconciliation, ordering of studies & tests, identification of definitive diagnosis, adjustment or maintenance of an established treatment plan, with documented follow-up of the plan.
• Liaises with current care team, community-based PCP & Specialists in provision of medical, behavioral & social determinants of health needs.
• Provides intermittent skilled care as needed (e.g. wound care).
• Documentation of all activities & results in Electronic Medical Record.
• Performs other duties as assigned.
• Ability to pass a fit test. Position requires mask where seal is critical. Incumbent is required to not have facial hair that interferes with a tight seal of the respirator.
• Frequent local travel.

Job Specification:

• Master’s Degree in Nursing, Board Certified NP with licensure in the Commonwealth of Massachusetts
• Massachusetts and DEA Controlled Substances licenses
• Clinical experience in primary care or care management, including 5+ years’ as RN in a high touch clinical environment or home care, or 3+ years as an NP in primary care of case management, & 2+ years caring for patients/members with complex medical, behavioral health & social needs
• Preferred experience with MassHealth & Medicare programming & insurance products (e.g., ACO, MCO, PACE, SCO)
• Candidate will need to pass Element Care & Commonwealth Care Alliance credentialing processes
• Bilingual Preferred
• Covid vaccines required.