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Form of workJob SummaryThe WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care.
Care is provided throughout the entire continuum of care - from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care. WellBe's physician/advanced practicing clinician led geriatric care teams' partner with the patient's primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.Job DescriptionGENERAL SUMMARYAs a Telehealth Care Delivery APP, you will play a vital role in managing, and delivering white-glove, high quality services to patients who need your help the most. The position will primarily be remote but will include occasional in-field visits to build patient relationships and foster WellBe's brand and reputation within the community.
You will be accountable for caring for patients via telehealth in tandem with a Telehealth Visit Facilitator, maintaining accurate and current patient records, and coordinating initial, urgent, and follow-up appointments with patients as required. You will be the quarterback of care across the broader patient care team including physicians, social workers, paramedics, LPNs and care coordinators to deliver high-quality, concierge-level care to every patient. You will help foster positive and effective working relations with senior leadership and management, local market management, and business ancillary departments for the purpose of achieving the company's vision, mission, and objectives.SKILLS & COMPETENCIES* Provides primary care via assisted Telehealth visits to patients in the home* Will support additional in- home, patient-facing visits to support patient care needs in the market* Partners with other clinicians in the "Care Community managing the health and wellbeing of patients living in their homes.* Responsible for engaging attributed patients into WellBe program* Facilitates staff, patient, and family decision making by providing educational resources.* Performs initial telehealth patient screenings/physical examinations and creates appropriate assessment/plan* Addresses urgent care needs of the patients as needed* Collaborates with community team as a Telehealth Visit APP or community based APP to complete care assessment* Orders, interprets, and analyzes diagnostic tests and determine the need for follow-up appointments and further treatment options* Prescribes and manage medications and treatments as appropriate, including but not limited to as* psychopharmacological agents* Updates patient records and check records for accuracy at each patient appointment* Delivers quality care while maintaining all company metrics pertaining to appropriate* Documentation/coding, HEDIS measures, engagement of patients, and managing medical expenses.* Serves as a resource for patients in delivering ongoing care information, counseling and guidance* for any patients with critical conditions* Refer to internal/external resources as appropriate such as WellBe behavioral health protocols* Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings* Maintain required licensure and certification* Deliver palliative care, and when needed, end of life care to patients and families* Facilitates family meetings with WellBe community team, to help with complicated family dynamics and goals of care* Other tasks needed to accomplish team's objectives/goalsJob RequirementsEducational/ Experience Requirements:* Minimum Master's Degree in Nursing* 3-5 years Nurse Practitioner experience, position does not allow new grads* Active Nurse Practitioner license in the state of practice and must reside in state.* Delivering telehealth and home visits to direct patient care required* Additional experience with telehealth care delivery preferred* Valid Nurse Practitioner license or the ability to obtain on in the state of operations* Current board certification in your field (ANP, GNP, FNP, etc)* BLS certified and an NPI# as an NP* Have a valid driver's license, car insurance, have access to a car and willingness to drive to patient* Requires homes visits to patient location occasionally* Requires proof of an active auto insurance policyRequired Skills and Abilities:* Ability to conduct telehealth visit and have previous experience on a telehealth platform* Requires that you have connectivity to perform audio and video consultation experience between patients and providers.
(Internet connection - broadband)* Role model in courageous teamwork, integrity, ethics, and productivity* Experience in diagnose and treat chronic and urgent medical/psychological conditions of older adults* Experience in end of life, geriatrics, internal medicine, palliative care* Experience in palliative care, and end of life communication* Excellent verbal, written, presentation, and interpersonal communication skills* Confident speaker to internal and external groups* Strong computer skills, including Word, Excel, and Powerpoint* Must be familiar with EHR medical documentation* Home care experience preferredSupervisory Responsibility: This position will have supervisory responsibility.Travel requirements: Position is primarily remote focused, with 30-50% travel into the field based on business needs.Work Conditions: Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assisting with weights of more than 100lbs. Ability to stand for extended periods.Ability to drive to patient locations (ie.
home, hospital, SNF, etc). Fine motor skills/Visual acuityThe preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position.
Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role
