Job Description Works as a provider member within the HBMC interdisciplinary team in the direct delivery of home-based medical care of a population within an assigned geography. Dedicated to improving the health and wellbeing of patients, this position collaborates with the PCP, HBMC interdisciplinary teammates and consultants, and as needed, the health plan Medical Director and other health professionals, to develop and carry out patients’ goals of care in all phases of the patient journey. SUMMARY • Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants. • Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable. • Performs an initial comprehensive assessment on all newly enrolled patients and provides ongoing care thereafter. Develops a patient management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with patients and/or their legal representatives to review newly developed or modified care plans; involves the PCP or supervising physician in these meetings, when applicable. • Completes follow-up and post-discharge assessments according to documented standard operating procedure. • Prescribes appropriate diagnostics and interventions to avoid unnecessary acute admissions. • Comfortable with basic procedures of nursing care, including IV placement, blood draws, injections, foley catheters, nasal packing, wound care, etc. New hire and annual skills check/training provided. • Consults with hospital, emergency or post-acute clinical team following notification of patient transfer. • Educates patients and/or their legal representatives in disease processes affecting patients and ways to manage them effectively, as well as to promote wellness. • Provides counsel, support and education to staff as appropriate. • Actively participates in ongoing meetings pertaining to patient care and clinical excellence • Implements HEDIS measure campaigns and other quality initiatives to ensure the highest standards of care and to promote the improvement of care management and delivery. • On-call for caseload during business hours. Participation in clinical after hours on-call program on rotational basis. • Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews. • Perform related duties as necessary and other duties as assigned. We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/. Skills and Requirements Education and/or Experience: o Completion of Nurse Practitioner accredited program o Minimum of two (2) years clinical experience, primary care, home-based medical care, geriatrics or palliative care or emergency/urgent care, desired o Knowledge of long-term care, community resources and cost-effective alternatives regarding patient care delivery systems o Knowledge of CPT, ICD-10 and HCPC codes o Knowledge of clinical standards of care o Awareness of NCQA requirements, CMS guidelines, Medicaid/Medicare contracts and benefit systems is helpful Certificates, Licenses, Registrations: o Current state RN license o Current NP license o Access to reliable transportation required; if you are driving a vehicle, you must comply with all the terms of the Optum Motor Vehicle Safety policy