Transitional Care Advanced Practice Provider (IL RBE)

Role Description

The Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes.

Our APPs lead a cohesive team of Oakies in delivering in-home support and care following adverse events, which include inpatient admissions.

APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up.

Provider teams enjoy easy access to clinical support from peers and medical directors and use best in class population health data to support patients when they need it most.

Core Responsibilities

Provide post-discharge support according to defined pathways within the patient's home

Develop care plans and individualize goals of care with patient, their families, and their providers

Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges

Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists

Structure and prioritize scheduling based on clinical complexity for both new and routine patients

Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions

Provide after-hours and weekend call support, shared with other in state providers

Facilitate and conduct goals of care and advance care planning discussions with patients and families

Assess and evaluate family / caregiver needs and limitations

Teach patients, caregivers, and others about their health conditions

Accurate and timely documentation of patient encounters in Oak Streetâ s electronic medical record

Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting

Other duties, as assigned

What are we looking for

Genuine passion for reaching vulnerable patients

Strong clinical skills focused on older adults with complex disease states

Comfort navigating visits in patient homes

Demonstrated ability to collaborate effectively in a team setting

Willingness to learn and be accountable for visit documentation and workflows

Excellent communication, follow-up, teamwork, and problem-solving skills

Desire to be a part of a fast-paced, innovative, quality-driven organization

Required Qualifications

Have an active, non-probationary state medical license, including US work authorization, if applicable

1+ years APN experience, preferably with a Medicare population

Experience in home-based care (as RN or APP) preferred

Flexibility to travel throughout service area

Electronic Medical Record experience

Computer skills : Ability to quickly navigate and use multiple computer programs to include, but not limited to : Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.

Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required