Focus: Primary Care | Complex Care Management |
Telehealth
Location: Ohio
Work Arrangement: Remote
Experience: 3+ Years of Primary Care Experience
Education: Master’s Degree or Higher
We are seeking an experienced Nurse Practitioner (NP)
to join a growing healthcare organization focused on delivering innovative,
patient-centered care to medically complex populations throughout Ohio.
This is an opportunity to move beyond the traditional clinic
setting and play a key role in a home-centered, value-based model of care.
The position focuses on proactive care management, early intervention, care
coordination, and improving outcomes for patients who often require a higher
level of clinical support.
The Nurse Practitioner will work as part of a collaborative
interdisciplinary team that may include physicians, Nurse Practitioners,
Registered Nurses, Licensed Clinical Social Workers, therapists, and other
healthcare professionals.
Through telehealth, remote care management, and
coordinated clinical services, the team works closely with patients,
families, caregivers, primary care providers, specialists, and health plan
partners to help patients remain healthy and safely at home.
Patient Population
The patient population may include Medicaid and Dual
Eligible members, including individuals with:
- Complex
chronic medical conditions.
- Physical
disabilities.
- Traumatic
brain injuries.
- Intellectual
and developmental disabilities.
- Functional
limitations.
- Medically
complex and aging populations.
- Multiple
chronic conditions requiring coordinated care.
The role is primarily virtual, with the potential for a
collaborative office presence in a major Ohio metropolitan area as the
organization continues to expand.
Key Responsibilities
- Provide
clinical care and ongoing patient management through telehealth and
remote care technologies.
- Manage
and coordinate care for medically complex adult and geriatric patient
populations.
- Partner
with physicians and interdisciplinary team members to develop and
implement individualized care plans.
- Build
strong relationships with patients, families, caregivers, primary care
providers, specialists, and health plan partners.
- Monitor
changes in patient health and intervene proactively to reduce avoidable
emergency department visits and hospitalizations.
- Support
patients through hospital admissions, discharges, and transitions back to
the home setting.
- Participate
in advance care planning and goals-of-care discussions with
patients and families.
- Participate
in shared clinical triage and team-based support processes.
- Identify
and address barriers to care, treatment adherence, and patient engagement.
- Support
quality improvement initiatives through accurate and timely clinical
documentation.
- Contribute
to HCC coding, risk adjustment, STAR, HEDIS, and quality-gap closure
initiatives.
- Participate
in the development of clinical best practices and contribute to the
continued evolution of an innovative care model.
- Promote
patient independence, safety, and improved quality of life through
proactive care coordination.
Required Qualifications
- Master’s
degree or higher in Nursing or a related field.
- Current
and active Nurse Practitioner license in Ohio, or ability to obtain
Ohio licensure.
- Current
Family Nurse Practitioner (FNP) or Adult/Adult-Gerontology Nurse
Practitioner (AGNP) certification.
- Minimum
3 years of primary care experience; 3–5+ years of Nurse
Practitioner experience preferred.
- Ability
to practice autonomously within applicable scope of practice and maintain
appropriate prescriptive authority.
- Experience
caring for medically complex adult and/or geriatric patients.
- Experience
with telehealth, virtual care, remote patient monitoring, or remote care
management.
- Knowledge
of or experience with HCC coding and risk adjustment.
- Familiarity
with quality measures and programs, including STAR and HEDIS.
- Experience
participating in advance care planning and goals-of-care discussions.
- Strong
clinical judgment, communication, collaboration, and relationship-building
skills.
- Ability
to work independently while effectively collaborating within an
interdisciplinary care team.
Preferred Clinical Background
Candidates with experience in one or more of the following
areas are encouraged to apply:
- Value-Based
Care.
- Population
Health.
- Home-Based
Primary Care.
- Geriatrics.
- Managed
Medicaid.
- Care
Management.
- Telehealth
or Virtual Care.
- Emergency
Medicine or Clinical Triage.
- Rehabilitation
or Neuro-Rehabilitation.
- Skilled
Nursing.
- Home
Health.
- Complex
Care Management.
Why This Opportunity
This position is ideal for an experienced Nurse Practitioner
who wants to make a meaningful impact on the lives of medically complex
patients while working outside the traditional high-volume clinic environment.
Rather than focusing solely on the number of patients seen,
this care model emphasizes proactive intervention, care coordination,
prevention, quality improvement, and patient-centered outcomes.
You will have the opportunity to:
- Build
meaningful relationships with complex patients and their families.
- Work
collaboratively with a multidisciplinary clinical team.
- Leverage
telehealth and technology to improve access and care coordination.
- Help
prevent avoidable hospitalizations and emergency department visits.
- Support
patients in living safely and independently at home.
- Contribute
to the development of an innovative, value-based healthcare model.
- Help
shape clinical processes and best practices as the organization grows in
Ohio.
If you are an experienced Nurse Practitioner seeking a mission-driven,
collaborative, and innovative clinical opportunity, this role offers the
chance to make a meaningful difference while helping transform how complex
patients receive care.