Nurse Practitioner or PA - Home Based Medical Care - Detroit, MI

In this role you work as a provider member within the HBMC interdisciplinary team in the direct delivery of home‑based medical care of a population within an assigned geography. Dedicated to improving the health and well‑being of patients, this position collaborates with the PCP, HBMC interdisciplinary teammates and consultants, and as needed, the health plan Medical Director and other health professionals, to develop and carry out patients' goals of care in all phases of the patient journey. This is a Monday‑Friday, days position with some rotating on‑call responsibilities. In this position you will be traveling to the home setting throughout the greater Detroit, MI area – several openings. Primary Responsibilities Conduct in‑home assessments on health plan members, including past medical history, review of symptoms, physical examination, medication review and depression screening. Practice in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants. Establish and maintain effective relationships with patients, caregivers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable. Perform an initial comprehensive assessment on all newly enrolled patients and provide ongoing care thereafter. Develop a patient management care plan upon enrollment and update it as needed when changes in condition warrant or following hospitalization. Meet with patients and/or their legal representatives to review newly developed or modified care plans; involve the PCP or supervising physician in these meetings, when applicable. Complete follow‑up and post‑discharge assessments according to documented standard operating procedure. Prescribe appropriate diagnostics and interventions to avoid unnecessary acute admissions. Comfortable with basic procedures of nursing care, including IV placement, blood draws, injections, foley catheters, nasal packing, wound care, etc. New hire and annual skills check/training provided. Consult with hospital, emergency or post‑acute clinical team following notification of patient transfer. Educate patients and/or their legal representatives in disease processes affecting patients and ways to manage them effectively, as well as to promote wellness. Provide counsel, support and education to staff as appropriate. Actively participate in ongoing meetings pertaining to patient care and clinical excellence. Implement HEDIS measure campaigns and other quality initiatives to ensure the highest standards of care and to promote the improvement of care management and delivery. On‑call for caseload during business hours. Participation in clinical after‑hours on‑call program on rotational basis. Keep current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews. Perform related duties as necessary and other duties as assigned. Since this position involves in-home visits, the ability to work autonomously and travel in your local area will be required. You should also be comfortable working with geriatric patients who have a variety of health complications. You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. #J-18808-Ljbffr Optum