Advanced Practice Clinician, Integrated Care Delivery; Pima

Overview

Advanced Practice Clinician, Integrated Care Delivery (Pima County). This role provides and coordinates primary care to SCAN members to achieve the Company’s mission to keep seniors healthy and independent.

We hire for this role on a rolling basis. If you're a match, we’ll reach out when a position becomes available.

• Provide care to an assigned panel of members (patients) in their place of residence, most commonly in senior living communities or skilled nursing facilities. This includes conducting physical/wellness exams and assessments; occasional urgent medical visits and telephonic triage to ensure timely, appropriate care and hospital avoidance if possible; administering vaccines; ordering and interpreting diagnostic tests; initiating goals of care conversations with patients and their loved ones;
  
  and chronic disease management.
• Identify patient health care needs and develop a comprehensive plan of care for the patient, their family, and living-community staff.
• Collaborate with our case management team to ensure members have timely access to necessary and appropriate services.
• Independently manage visitation schedule in line with established practice protocols and adjust schedule based on members’ needs and acuity.
• Engage with Primary Care Physicians and other health care professionals in a collaborative relationship aimed at disease prevention, health promotion, and chronic disease management. Partner closely with Primary Care Physicians for clinical oversight and guidance.
• Connect with specialists, hospitals, ancillary care providers, and community-based organizations to ensure continuity of care and promote shared decision-making while advocating for members.
• Actively monitor and address clinical quality gaps in care in partnership with other care providers.
• Document member visits and interactions in a timely manner according to established practice protocols.
• Serve as an ongoing direct resource for members and their families, as well as for their communities and support staff.
• Participate with Integrated Care Sales team in events to build member awareness and educate communities.
• Initiate and complete virtual health visits with members as needed to promote accurate triaging and reduce drive time.
• Participate in on-call program available to our members after hours and on weekends.
• Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications.
• Contribute to team efforts to meet quality healthcare goals by closing care gaps, attending high risk group discussions, and optimizing clinical workflows and protocols.
• This position is a patient-facing role.
• Employees may be eligible for differential pay.
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

• Master’s degree in Nurse Practitioner Certificate OR Master’s from an accredited PA program, Education in Adult/Geriatric medical care preferred.
• A comparable combination of education/experience and/or training will be considered equivalent to the education listed above.
• Current Arizona Nurse Practitioner license OR Arizona Physician Assistant Certification (PA-C) in good standing.
• Wound Care Certificate and Palliative Care Certificate a plus.
• Knowledge of the treatment of complex chronic diseases, such as dementia, diabetes, heart failure, and COPD.
• Ability to identify health care needs and refer and coordinate with other resources/programs appropriately.
• Knowledge of HCC and ICD-10 coding and documentation.
• Knowledge of wound care and management.
• Knowledge of CMS guidelines and Medicare Advantage Managed Care.
• Comfortable with initiating goals of care and end of life discussions.
• Strong interpersonal skills and change agent mindset needed to build relationships with healthcare team and patients.
• Knowledge of and ability to maintain HIPAA requirements.
• Adaptable and open to change and problem-solving.
• Knowledge of and/or ability to learn basic technological skills (Word, Excel, PowerPoint, Outlook, EMR) and open to new technology.
• Ability…