Position : Field Advanced Practice Provider
The Monogram Advanced Practice Provider is a Nurse Practitioner is a critical role that provides access to comprehensive care to underserved patients within their assigned territory. The Advanced Practice Provider will be responsible for delivery of personalized compassionate medical care to patients primarily with CKD through ESRD. The Advanced Practice Provider will be responsible for caring for patients, maintaining accurate patient records and scheduling and administering follow-up appointments to patients as required across multiple markets. The successful candidate will work as a team with our field-based nurses, community health workers, and physicians to assist in delivering premium care to every patient. Primary duties include patient health assessment, creating strategies to improve or manage a patient's health, and introducing habits for health promotion. Advanced Practice Providers perform the important task of educating patients about preventative care and prescribed treatments. He / she may also conduct physicals, order tests, prescribe medications, and serve as a coordinator with the patient's primary healthcare provider and their specialists.
Roles and Responsibilities
- Travels throughout assigned territory to conduct home conducts in-home assessments, which include comprehensive annual wellness exams, focused screenings, or other visits both in the patients' home and in the virtual environment
- Ability to travel out of state for up to 2-weeks at a time as necessary
- Counsels and educates patients and families about benefits and programs available to help them live healthier lives
- Documents items such as : appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan
- Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services
- Completes all documentation and paperwork in a timely manner
- Maintains quality of care standards as defined by the practice
- This position will not be office-based but will be remote in state in which employed and will need to attend periodic training / meetings outside of that state
- Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first
- Prescribe medications, order tests, and collaborate with patient’s Monogram physician
- Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily
- Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing
- Assists patients with enrolling to access educational videos
- Participates in the integrated care team meetings
- Knowledge of disease diagnosis and prevention
- Make assessment of patient's health status
- Develop treatment plan
- Implement a plan consistent with appropriate plan of care
- Follow-up and evaluate patient's status
- Other duties as assigned
Position Requirements
Must be able to commit to travel at least 50% of the time. If over 2 hours, candidate can rent a car. Driving or flying is an option.Active and unrestricted Registered Nurse and Nurse PractitionerBoard certified for appropriate licensure (NP : ANCC / AANP)Current and unrestricted DEA certificateAbility to travel up to 75% of the timeAbility to work without direct supervision and practice autonomouslyAccess to transportation, a valid driver's license, and car insuranceMust be proficient with medical instruments and equipment required by the workKnowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technologyAbility to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the communitySound understanding of all federal and state regulations including HIPAA and OSHA2 or more years of direct patient care requiredBilingual in Spanish is a plus; but not requiredManaged Care / IPA / Health Plan experienceExperience conducting wellness visits, focused assessments, or similar comprehensive visits virtually or in the homeBenefits
Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of polychronic careCompetitive salaryComprehensive medical, dental, vision and life insuranceFlexible paid leave and vacation policy401(k) plan with matching contributionsAbout Monogram Health :
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.
Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.
Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.
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