Utilizes data and risk stratification to identify high risk patients to prioritize outreach and gap closure defined by best evidence • Supports transitions of care and reduced readmissions and ED use • Proactively participates in quality improvement initiatives to enhance care delivery and care outcomes • Supports proactive outreach to populations at greatest risk • Collaborates with a multidisciplinary team physicians/APPs, RNs, Pharmacists and care coordinators/community health workers • Participation in team meetings Citizenship • Demonstrates the MultiCare values of compassion, stewardship, kindness, joy collaboration and respect • Adheres to MultiCare policies and processes Requirements • Maintains active Washington State Nurse Practitioner or Physician Assistant license • DEA, and state prescriptive authority • Current BLS for Healthcare Providers certification by the American Heart Association. This role requires collaboration with physicians, RNs, pharmacists, social workers, behavioral health specialists and other professionals to optimize the health of MultiCare communitiesResponsibilities Direct Patient Care • Conducts comprehensive assessments, diagnose conditions, develop plans, and prescribe medications for patients across the lifespan • Diagnoses and treats acute and chronic disease using evidence-based guidelines • Refers to specialists when necessary • Participates in the coverage for clinic colleagues per departmental guidance • Participates in after-hours call coverage per departmental guidance • Timely and accurate documentation, inclusive of direct patient encounters and asynchronous care Population Health and Clinical Quality • Ensures comprehensive primary care for a population including risk assessment, preventive care and oversight for optimal management of chronic conditions including the cardiovascular- kidney- metabolic syndrome.