Details/Responsibilities:
- Full-time, Mon - Fri, 8am-5pm
- Deliver high-touch, high-quality care to the highest risk patients within their homes
- This role is supported by a scribe/medical assistant, nurse, social worker, and other resources.
- NPs make 6-7 visits daily in a defined territory and collaborate continuously with other team members for care coordination and all other needs.
- 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.
- 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 electronic medical records
- Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
- Other duties, as assigned
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
Compensation & Benefits:
- Competitive Salary
- Paid vacation, sick time, and investment/retirement 401K match options
- Health insurance, vision, and dental benefits
- Opportunities for leadership development and continuing education stipends
- New centers and flexible work environments
- Opportunities for high levels of responsibility and rapid advancement
The Community:
Experience the perfect blend of peaceful living and vibrant community life in a region where rolling hills meet revitalized downtowns, and affordability goes hand-in-hand with opportunity. This area offers a welcoming, family-friendly atmosphere with excellent schools, diverse dining, and a growing arts and culture scene. Residents enjoy access to scenic parks, hiking trails, and local festivals, as well as a strong job market in healthcare, manufacturing, education, and logistics. With easy highway access to major cities like Philadelphia and New York, it’s an ideal location for those seeking a balanced lifestyle—where small-town comfort meets big-city convenience.
APPLY NOW or TEXT Job #CMW231877 and email address to 636 - 628 - 2412.
Search all of our provider opportunities at:
brittmedical DOT com
