Nurse Practitioner, House Calls Program (Mso)

Role Description

The @HOME Nurse Practitioner delivers high-touch, high-quality, home-based primary care to the highest risk patients. Our NPs lead a cohesive team of Oakies to provide wrap-around, comprehensive, in-home support and care. NPs, along with their Medical Assistant/Scribes, make 4-6 visits daily in a defined territory and collaborate continuously with other team members for care coordination, social services, and behavioral health care. Provider teams enjoy easy access to clinical support from peers and medical directors, tailored clinical education for in-home providers, and dedicated non-clinical time for panel management and patient discussions, using best in class population health data. This is a traveling position that provides in-home primary care to medically complex seniors.

Program Overview

The House Calls Program (known as @HOME) delivers high-quality primary care to Medicare patients in their home. The @HOME program takes a team-based approach to providing outstanding patient care. Our Care Teams - consisting of a Provider, Medical Assistant/Scribe (CIS/MA), Behavioral Health Specialist (BHS) and Mobile Operations Coordinator (MOC) - build individual relationships across a small panel of patients, seen monthly. The Care Team is responsible for delivering excellent, high-touch primary care, and coordinating the care of patients.

Core Responsibilities

• Provide longitudinal care to high frailty patients according to defined pathways within the patient's home

• Develop care plans and individualize goals of care with patient and families 

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

• Collaborate with home health, specialists, 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 

• 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

• Embrace Oak Street Health care and risk model, including clinic workflows that support panel health and accurate coding

• Accurate and timely documentation of patient encounters in Oak Street'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 primary care and 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 APN) 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

• US work authorization

• Someone who embodies being 'Oaky'

What does being an Oaky look like?

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being relentlessly determined

Why Oak Street Health?

 Oak Street Health is on a mission to "Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities and focused on the quality of care over volume of services. We are an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission. 

Oak Street Health Benefits: 

• Mission-focused career impacting change and measurably improving health outcomes for Medicare patients

• Paid vacation, sick time, and investment/retirement 401K match options

• Health insurance, vision, and dental benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply. 

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health