Nurse Practitioner

Nurse Practitioner

Alameda County, California

Company Overview:

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It's no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description:

The Nurse Practitioner (NP) is responsible for providing high-quality, patient-centered, comprehensive primary care. Utilizing Upward Health's proprietary Facilitated Virtual Care platform, the NP delivers care that improves outcomes and reduces costs for patients with complex diagnoses and co-morbid, chronic conditions. This role primarily involves virtual patient care with periodic or as needed in-person care to support transitions of care, annual wellness visits, risk adjustments, primary care needs, and urgent visits. The NP collaborates closely with a multidisciplinary team to provide whole-person care to our patients in their homes.

Key Responsibilities:

• Triage, diagnose, and treat patients in person or via our virtual care platform.
• Serve as a day-to-day clinical leader, providing decision support and directing the multidisciplinary team under the guidance of the Medical Director.
• Conduct primary care, urgent visits, and annual wellness exams, ensuring all appropriate screening tests and quality measures are addressed.
• Refer patients appropriately for behavioral health and specialty services.
• Coordinate care transitions to prevent hospital readmissions by collaborating with PCPs, hospitalists, and SNF providers.
• Participate in the on-call provider schedule to support the 24/7 patient hotline, requiring after-hours and weekend availability on a rotating and recurring basis.
• Foster a collaborative working environment with all members of the interdisciplinary team, contributing to daily huddles, team meetings, and patient discussions.
• Monitor and respond to remote patient data collected through monitoring devices.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Perform and document accurate and thorough risk assessments for the purpose of accurate documentation of condition(s).
• Expertise in managing complex, polychronic patients, with demonstrated ability to assess and treat high-acuity patients.
• Familiarity with caring for Medicare and Medicaid populations, with experience in both inpatient and outpatient or home care settings.
• Proficiency in motivational interviewing, trauma-informed care, and supporting vulnerable populations is preferred.
• Excellent written, computer, and oral communication skills, with the ability to communicate efficiently and proactively with the clinical team.
• Dedication to health equity and transforming care for patients in their homes.
• Strong organizational skills and ability to provide clinical leadership and coordination.

Qualifications:

• Minimum of 5 years' experience as a provider, with a minimum of 3 years in a primary care, or related, setting.
• Multi-state Advanced Nursing License or willingness to obtain.
• A valid driver's license and auto liability insurance.
• Willingness and ability to travel as needed, though responsibilities are primarily performed virtually.
• Experience in urgent/emergent care settings is a plus.

Key Competencies:

Clinical Leadership:

• Ability to provide decision support and leadership to the care team.

Patient-Centered Care:

• Focused on delivering high-quality, compassionate care to improve patient outcomes.

Collaboration:

• Works effectively within a multidisciplinary team to provide comprehensive care

Adaptability:

• Thrives in a dynamic, fast-paced environment with evolving protocols.

Problem-Solving:

• Proactively identifies and addresses challenges in patient care and team coordination.