The primary role of the Nurse Practitioner position is to support providers in delivering high-quality care and succeeding within a value-based care model.  To advance this purpose, the Nurse Practitioner provides Health Risk Assessments for Medicare Advantage patients of the primary care physicians we serve, performs comprehensive assessments in the physician’s office that comply with annual wellness visit requirements, and assists with accurate and complete chronic condition diagnosis coding.

Responsibilities include:

        Work with key physician practices that have a large number of open conditions and / or high suppression rates. Work to be done virtually as well as in office.  Review patient charts for assessment of suggested and suppressed diagnosis codes.  Update charts to capture additional diagnosis codes as appropriate.

        Development, implementation and adoption of various clinical guidelines across the network 

        Identification of Medicare patients appropriate for Annual Wellness Visits (AWV) and execution of guided processes to complete the AWV.Complete a detailed evaluation of the medical and social assessment of the beneficiary members. 

        Lead team-based clinical reviews of high risk and multiple-comorbidity patients

        Identify and refer members/patients for routine, urgent, and emergent case management. 

        Make recommendations for members’ follow-up visit with their primary care physician.

        Fall risk assessment/functional assessment.

        Ordering immunizations and preventive health screenings including Colonoscopy, Breast Cancer screening, and diabetes eye exams.

        Advance Care Planning and POLST education

        Update and reevaluate chronic conditions and YOY (year over year) diagnoses following CMS guidelines and HCC coding.

        Identify diagnoses and develop a proper care plan for chronic disease management.

        Educate and assist with coordination of preventive screenings such as mammograms, colorectal, immunization status, etc.

        Provide patient/family/caretaker education and facilitate patient empowerment and quality of life as appropriate.

        Provide clinical expertise in various pilots and initiatives adopted by the Medicare Advantage program

        Prepare and present educational sessions for clinicians and office staff on various initiatives and best practices