Job Summary
This Community Based Advanced Practice Provider, Nurse Practitioner or Physician Assistant in Columbus focuses on providing both urgent and primary care to our members where they live. Working in partnership with the member s primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.
Duties and Responsibilities
- Provide community-based medical and care-coordination services for recent hospital discharges
- Work closely with the transitional care manager and the member s primary care team, following through on the discharge plan with the member.
- Conduct patient/member assessments.
- Review, monitor, adjust and discontinue medications.
- Comprehensive Medication Review for adherence.
- Patient/Member and family education.
- Coordinate home care agencies and services.
- Develop and implement plan of care.
- Communicate patient s medical, or mental conditions, substance abuse and social determinants of health needs.
- Document appropriately in the Electronic Medical Record.
- Gather critical information from member s home environment and coordinates use of this information with healthcare team.
- Work collaboratively with the primary care provider, interdisciplinary office care team and transitional care manager,
- Support safe discharge transition and treatment in the community.
- Intervene with at-risk members to avoid unnecessary hospitalizations.
- Coordinate with care team, patient/member, family, and caregivers to help resolve barriers to care and transition back to Medical Center setting.
- Maintain the security and privacy of all information that is owned by AbsoluteCARE or maintained on behalf of the company s patients, employees, and business partners.
- Nothing in this job description restricts management s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned.
