Responsibilities will include:
- Patient Care Delivery
- Delivers virtual and in-person visits for patients with significant physical, behavioral, and social complexity, meeting patients in their homes or other safe environments to ensure appropriate, patient-centered care
- Depending on market needs, may also deliver primarily virtual (video and video facilitated) visits for low and rising risk patients and a subset of higher risk patients in more distant geographies to ensure appropriate, patient-centered care
- Guarantees every patient is seen face-to-face annually and proactively completes additional visits when clinical needs or care gaps arise
- Onboard patients into our care model with a Health Advocate, including performing a comprehensive biopsychosocial assessment and medication reconciliation in order to ensure accurate and appropriate diagnosis and evidence-based treatment for chronic conditions as well as preventative care gaps
- Conduct follow-up visits with patients to guide and oversee the medical management of patients’ chronic and urgent conditions to maximize patients’ healthy days at home
- Conduct post-hospital / ED visits in order to ensure appropriate transition of care and reduce risk for avoidable readmission
- Create and adjust patient care plans in collaboration with other Accompany Health team members, ensuring appropriate referrals or delegation of key actions to address key barriers and obstacles to health
- Provide clinical coverage as needed, including home-based follow-up and urgent visits
- Participate in a rotating call schedule to manage patients’ urgent needs
- The assigned geographic area (subject to change) may include locations requiring variable drive times; however visit and travel times will be scheduled to fit within the standard workday
- Interdisciplinary Collaboration
- Work in close collaboration with Health Advocates - providing clinical support, coaching and guidance to their activities to help them coach and empower patients on successful self-management of their health
- Refer, collaborate and co-manage patients with our behavioral health, nursing and pharmacy teams
- Collaborate with external providers and community organizations to ensure care aligns with patient goals as well as social, home health, and DME needs
- Clinical Diagnosis and Documentation, Quality, and Compliance
- Ensure accurate and appropriate diagnosis, coding and documentation of chronic conditions with evidence-based treatment plans
- Maintain timely, accurate documentation in EMR and custom care platforms
- Own the quality of preventative care delivered by helping patients close HEDIS quality gaps
- Technical Fluency and Innovation
- Quickly learns and adapts to new tools, software, and systems—including AI-driven solutions—that support patient engagement, care coordination, and clinical decision-making
- Understands the intersection of healthcare and technology, leveraging data-driven platforms, electronic medical records, and AI-enabled insights to independently problem solve and improve patient outcomes and operational efficiency
- Performs other duties as assigned
What makes you a fit for the team:
- Committed to serving complex, historically underserved patients with co-occurring medical and behavioral health conditions through an integrated, tech-enabled care model
- Strives to exceed expectations and dedicated to delivering high-quality, compassionate care to all patients, regardless of background or need
- Thrives in a fast-paced environment and able to adapt and contribute to continuous improvement
- Comfortably manages high volumes of work, and adapts quickly as priorities shift
- Bringing experience and comfort delivering high-volume care in fast-paced settings such as Urgent Care, the ED, or busy primary care/FQHC environments
- Demonstrates a strong clinical ‘detective’ mindset, investigating across multiple systems to uncover the right diagnosis and supporting evidence, consistently seeking the ‘how’ and ‘why’ while thoroughly documenting patients’ conditions and needs
- Shows adaptability and a strong growth mindset, including the willingness to unlearn prior workflows and embrace new approaches
- Exhibits calm, confident clinical decision-making even in ambiguous or rapidly changing situations
- Works collaboratively with teammates and actively seeks opportunities to learn, grow, and elevate team performance
- Displays trust in the organization’s mission, values, and direction, and contributes positively to a culture of shared purpose
- Highly organized and efficient, able to balance time and needs across a complex patient panel
- Motivated by advances in technology and excited to incorporate new technology and systems into daily practice
- Embraces continuous learning, coaching and feedback to enhance own skills in service of patient outcomes
- Strong communicator and clinical leader skilled in coaching, mentoring, and collaborating across clinical and non-clinical teams to promote excellence in patient care
Desired skills and experience:
- Required
- Active Nurse Practitioner (NP) or Physician Assistant (PA) license in state of employment and willingness to obtain additional licensure as requested
- Active DEA registration or eligibility to obtain (X-waiver preferred)
- Active or eligible state-controlled substance license
- Current Basic Life Support (BLS) certification
- 3+ years’ of experience in adult internal medicine, family medicine, geriatrics, or addiction medicine
- Strong clinical judgment and ability to make independent medical decisions
- Proficient in electronic medical record (EMR) systems
- Valid unrestricted driver's license and access to an insured vehicle for daily use
- Preferred
- Brings experience delivering high-volume care in fast-paced settings such as Urgent Care, the ED, or busy primary care/FQHC environments
- Experience engaging patients with chronic mental illness and substance use disorders
- Proven success collaborating within multidisciplinary care teams
- An understanding of managed care including how to appropriately assess STARS/HEDIS measures, code clinical comorbidities, and identify clinical care gaps
- Hands-on experience working with AI tools in a clinical healthcare setting