Clinical Practice & Patient Management
Comprehensive Primary Care: Conduct physical exams, diagnose acute and chronic conditions, and develop longitudinal treatment plans for adult and geriatric patients.
Chronic Disease Management: Take the lead on managing "high-touch" patients with complex comorbidities (Diabetes, CKD, CHF, Hypertension) to prevent disease progression.
Preventive Care & Wellness: Perform Annual Wellness Visits (AWVs), focusing on preventive screenings, immunizations, and cognitive assessments.
Medication Management: Review and reconcile medications to reduce polypharmacy risks and improve adherence, especially for patients transitioning from hospital to home.
Value-Based Care (VBC) & Quality Focus
Documentation & HCC Coding: Ensure all clinical documentation is thorough and captures the full complexity of the patient's health to support Hierarchical Condition Category (HCC) coding and RAF accuracy.
Closing Care Gaps: Proactively identify and close HEDIS and Stars quality gaps during every patient encounter (e.g., ensuring A1c tests, colonoscopies, and bone density scans are completed).
Utilization Management: Work to reduce unnecessary ER visits and hospitalizations through same-day "sick" appointments and diligent follow-up.
Transition of Care (TOC): Conduct timely post-discharge visits to ensure patients have their medications and follow-up tests, reducing 30-day readmission rates.
Collaboration & Communication
Interdisciplinary Teamwork: Collaborate daily with the attending Physician, Medical Assistants, and Care Coordinators to execute the patient s care plan.
Patient Advocacy: Act as a primary point of contact for patients and their families, providing education on disease processes and self-management.
Specialty Coordination: Communicate with specialists to ensure a "closed-loop" referral process, ensuring that specialist recommendations are integrated into the primary care plan
Qualifications: APRN / PA-C
Education: APRN: Master s or Doctoral degree in Nursing (NP) from an accredited program.
PA-C: Master s degree from an ARC-PA accredited Physician Assistant program.
Certification: APRN: Board Certification (ANCC or AANP) in Adult-Gerontology (AGNP) or Family (FNP).
PA-C: Current certification by the NCCPA.
Licensure: Active, unrestricted license to practice in the State of Florida.
Experience: 2+ years of experience in primary care or geriatrics is preferred. Experience in a Value-Based Care or Medicare Advantage environment is a major plus.
Skills: Proficiency in EMR documentation (e.g., eClinicalWorks, Athena).
Must be bilingual in Spanish and English
Strong understanding of HCC/RAF coding and HEDIS quality metrics.
Excellent communication skills with a focus on an empathetic patient experience.
