Value Based Care Nurse Practitioner / Physician Assistant (NP or PA)

Value Based Care Nurse Practitioner / Physician Assistant (NP or PA) Duties and Responsibilities Direct Clinical Care & Billable Services Perform comprehensive, billable patient visits in virtual, clinic, or community-based settings, including: Annual Wellness Visits (AWVs) Chronic Care Management (CCM) Transitional Care Management (TCM) Primary care and follow-up visits Conduct complete medical histories, physical exams, and risk assessments. Diagnose and manage acute and chronic conditions within scope of practice. Order, interpret, and follow up on diagnostic tests and labs. Prescribe medications and treatments in accordance with state law, protocols, and collaborative agreements. Refer patients to specialists or supervising physicians when clinical needs exceed scope. Provide health education, preventive counseling, and self-management support to patients and caregivers. Population Health & Value-Based Care Activities Identify, document, and accurately code chronic conditions (HCC/RAF) to support risk adjustment and appropriate reimbursement. Close gaps in care related to preventive screenings, immunizations, and chronic disease management. Develop and implement individualized, longitudinal care plans in collaboration with patients and care teams. Utilize population health data, registries, and dashboards to prioritize high-risk patients. Support achievement of quality benchmarks, including HEDIS, STAR measures, UDS-related measures, and payer-driven metrics. Contribute to reducing hospital admissions, readmissions, and emergency department utilization. Care Coordination & Interdisciplinary Collaboration Collaborate closely with physicians, clinical pharmacists, nurses, case managers, social workers, and community partners. Participate in interdisciplinary team meetings, case conferences, and care planning discussions. Communicate effectively with health plans, payers, hospitals, and post-acute providers to ensure continuity of care. Support transitions of care and timely post-discharge follow-up. Clinical Leadership, Oversight & Quality Improvement Provide direct supervision, clinical guidance, mentorship, and support to APPs, licensed, and unlicensed population health staff as assigned. Assist with onboarding and training related to workflows, documentation standards, and value-based care principles. Participate in performance improvement (PI) and quality improvement initiatives. Contribute clinical insight to workflow optimization and care delivery model development. Participate in payer meetings or internal reviews related to quality, utilization, and performance outcomes. Documentation, Compliance & Professional Practice Ensure timely, accurate, and compliant documentation in the EHR to support billing, quality reporting, and regulatory requirements. Maintain licensure, certification, prescriptive authority, CPR certification, and credentialing requirements. Adhere to organizational policies, HRSA/FQHC standards, and scope-of-practice regulations. Demonstrate flexibility and adaptability to meet changing organizational and patient needs. Perform other duties as assigned by Population Health or Clinical Leadership. Qualifications Education & Licensure /Experience Licensed Nurse Practitioner (FNP, AGNP) or Physician Assistant in the State of South Carolina. National board certification (FNP-C, AGNP-C, PA-C). Master's degree in Nursing or Physician Assistant Studies required. Current prescriptive authority and DEA registration. Current CPR certification. Experience in primary care, family medicine, internal medicine, geriatrics, or population health preferred. Experience with AWVs, CCM, TCM, and value-based care visits strongly preferred. Knowledge of HCC/RAF coding and quality metrics preferred. Prior leadership, mentoring, or supervisory experience preferred. Experience working in FQHCs or managed care environments a plus. #J-18808-Ljbffr