Value Based Care Practitioner

JOB SUMMARY:

Motivated and self-sufficient professional to work closely with the Medical Director of Population Health to address targeted care needs of patients of Chase Brexton Health Care. A successful candidate will be highly committed to the organization's mission and values, will be a team player, and will possess the clinical skillset required to address a variety of value-based care priorities as defined within value-based care (VBC) contracts, including conducting Annual Wellness Visits and inpatient hospital follow up visits. The role will include a schedule of billable visits and may evolve to include addressing cross-team administrative issues such as covering planned provider outages. The successful candidate will be flexible and adaptable to different primary care provider styles, while ensuring alignment with VBC principles and targeted care measures, such as providing extended prescriptions and promoting adherence to chronic disease management plans. This position will not carry a panel and will be subject to unique productivity assessments. Evaluation of the role's success will be determined by the supervisor (Medical Director of Population Health), with evolution of the role in response to organizational VBC contracts, in alignment with broader organizational priorities.

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking

* Work closely with primary care team to coordinate patient care needs and progress on established care plans;

* Review existing plans of care and follow through on those, and update as needed to align with the latest clinical guidelines, in partnership with patient and family preferences and needs;

* Contribute to patient risk stratification policies and systems.

Patient Focus

* Assist patient to prioritize care needs that are "high-value", i.e., USPSTF Grade A & B recommendations and others recommended for improving outcomes of chronic disease;

* Use healthcare data from the EMR, CRISP, local healthcare portal systems, to optimize use of healthcare resources and convene relevant specialty care recommendations with that of the primary medical home;

* Assist in identifying individuals and populations and connect to relevant resources to improve adherence, reduce utilization, and ensure optimal outcomes.

Checking, Examining, and Recording

* Maintains complete and comprehensive clinical plans.

* Timely completion of clinical documentation.

* Follow through on positive screening results.

* Addresses administrative coverage tasks within policy-defined timeframes.

SKILLS AND ABILITIES:

* Licensed nurse practitioner or physician assistant

* Ability to work within multi-disciplinary clinical team

* Facility with Microsoft Office Suite (SharePoint, Outlook, Word, Excel)

EDUCATION AND/OR EXPERIENCE

* Required: Master's degree from an accredited program in relevant clinical practice (NP/PA).

* Preferred: Doctoral degree in nursing practice, primary care practice experience, telehealth experience, previous FQHC experience, MPH or other public health related degree and experience.

* At least 2 years of experience.

* Appropriate Maryland licensure and clinical certification, DEA and Maryland CDS, X license interest in and/or experience in community health settings.

* Ability to work harmoniously with diverse groups of individuals.

* Excellent communication and team skills required.

WORKING CONDITIONS

* Hybrid position;

* Must reside in Maryland;

* Schedule will be developed in partnership with clinic leadership and evolving organizational needs;

* This role offers a high degree of critical thinking and autonomy, and is best filled by a "self-starter";

* Travel among Chase Brexton sites may be required.