Advanced Practice Provider: Complex Geriatric Care

Job Description

This position is a fully remote role and requires working hours in EST or CST. An active and clear RN and APRN or Physician Assistant license in GA, PA, and/or OH is required at time of hire. A bit about this role: The Gold Care Program is a highly collaborative, multidisciplinary team of physicians, advanced practice providers, nurse case managers, social work case managers, community health workers, and scheduling team, united by our mission to build a better care delivery system for Devoted’s most complex members. We provide whole-person clinical, social and logistical support for patients with complex chronic conditions, frail elders, and patients at high risk of hospital admissions. The Advanced Practice Provider (APP) role on the Gold Care team is to reinforce and adjust the patient’s plan of care according to what matters most to the patient, their clinical picture, and in response to any barriers or obstacles they are facing. They manage the clinical trajectory of the patient including symptom management, chronic disease management, and adjustments to the clinical plan. The NP’s clinical decision making and bias-to-action ensures we continuously deliver on meeting patients’ needs as determined by both the interdisciplinary team and by the patient’s priorities. Responsibilities and Impact will include: Deliver exceptional care to a cohort of complex patients across multiple geographies, leveraging video telehealth visits and an interdisciplinary team. Guide and oversee the medical management of patients (utilizing the 5M framework) during their tenure with Gold Care. Work closely with other members of the patient's care team including their PCP, specialists, and other Devoted teams such as pharmacy, or specialty care. You will also collaborate with the patients’ support systems such as family members and caregivers in order to coordinate care for the patient and deliver a collaborative care plan. For patients in Gold Care, perform comprehensive assessment visits, provide post-acute transition support, comprehensive diagnosis/disease review, medication review, and assessment for quality of care (Stars/Hedis) interventions as well as social and home health/DME needs. In infrequent instances when appropriate and compliant with NP licensure, you may also provide telehealth visits to members outside of your panel to support other Devoted Medical service lines As the program continues to grow, there may be an infrequent weekend on-call component to support our clinical nurses who triage calls from our members during the weekend. Maintain accurate and up-to-date patient medical records, ensuring compliance with relevant legal and ethical guidelines. Adhere to all relevant laws, regulations, and industry standards, including patient privacy and telehealth regulations. Required skills and experience: An active and clear RN and APRN or Physician Assistant license in GA, PA, and/or OH is required at time of hire and must be maintained while employed at Devoted Medical with a willingness to obtain and maintain multiple state licenses Three or more years working as an APP with experience in primary care, house calls, internal medicine, family medicine, geriatrics, and/or palliative care Proficiency in using telehealth technology and electronic health records (EHR) Active BLS at time of hire and must maintain while employed at Devoted Medical Desired skills and experience: Virtual care experience is preferred with a strong desire to continue practicing clinical nursing and perform virtual visits - you believe in the mission of bringing care to where the patient lives Experience providing clinical care in collaboration with interdisciplinary teams is preferred Experience working with complex, frail, or vulnerable populations, including in Skilled Nursing Facility (SNF) setting Team player, continuous improvement mentality and can-do attitude Experience working in a fast-paced, high-energy organization Ability to adapt quickly and maintain flexibility with new workflows Proficiency in English and Spanish preferred for this position, but not required