Nurse Practitioner

3 days ago

Jakarta, Indonesia Agilon Health Full time

Company:
MDX Hawai'i, Inc.

**Location**:
Remote - HI

Job Title:
Nurse Practitioner

**Job Description**:
The Nurse Practitioner (NP)/Advanced Practice Nurse (APRN) is a licensed independent practitioner who provides clinical assessment and care to assigned patients including assessments of health plan members in their homes, and in clinics and facilities. The responsibilities include: adult/geriatric assessment, medical history, physical exam, medication reconciliation, risk assessment, diagnosis, and health education of member/family on various aspects of their health care, disease process and expectations. Additionally, patient education, communication to the PCP, follow-up facilitated with the PCP, and case management referrals may also be part of any assessment. Clear documentation, according to CMS and federal and state guidelines and protocols, is required. Other clinical care services may be required within the NP/APRN scope of practice, including but not limited to annual health assessment evaluations, post hospital follow up, post hospital or SNF medication reconciliation, etc. Nurse Practitioners are expected to achieve MDX Hawai’i standards for quality, customer service, productivity and teamwork through participation in Quality programs, provider education sessions, clinical meetings and other meetings as required.

TYPICAL WORKING CONDITIONS:
Field based position; Incumbent will work in the office setting, provider office settings and other locations where demonstrations, evaluations and/or training sessions are performed. Requires travel via own automobile throughout O‘ahu. Required day and/or overnight travel to Neighbor Islands may be warranted at times. Requirements as set forth in the specific contract for the site may include working flexible hours including evenings, nights and weekends.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Effectively demonstrate the ability to identify, accurately diagnose, assess / reassess and document on primary care chronic disease diagnoses, utilizing the CMS - HCC risk adjustment model. Recognizes the needs of clinical complex patients, conditions, characteristics and behaviors that place patients at risk.
- Order and interpret diagnostic and therapeutic tests relative to patient’s age-specific needs and to identify and assess patients’ clinical problems and health care needs, recommend appropriate follow-up and reconciles medications.
- Accurately complete AHAs and/or AWVs consistent with CMS policies and protocols.
- Identify unmet gaps in care, and provide appropriate recommendations to PCP and/or specialists in a timely manner.
- Provide timely disposition forms to PCP and/or specialists on the day of the visit. Notify PCP of record of any urgently needed follow-up as needed and assist the patient to make this follow-up as needed. Activate 911 if needed for emergencies.
- Provide instruction to patient and recommend appropriate follow up to patient in a clear manner.
- Prescribe or recommend medications or other forms of treatment such as physical therapy, inhalation therapy, or related therapeutic procedures
- Work collaboratively with various MDX Hawaii physicians in the community and their associated staff and assist in logistics and scheduling of these appointments as needed, case managers, social workers, family members, key care givers and any appropriate ancillary medical personnel as appropriate and assist in scheduling appointments as needed.
- Provide education, training and support to as needed to MDX Hawaii physicians as needed.
- Function independently to perform age-appropriate, comprehensive history and physicals called Annual Health Assessments (AHAs) or Medicare Annual Wellness Visits (AWVs) to provide appropriate preventive health measure recommendations and screenings in various settings: in the patient home, in the physician office or facility settings.
- Accurately complete summary and care management referral forms. Create a comprehensive plan of care which is individualized to the member and consistent with CMS policies and protocols. Identify unmet needs and gaps in care. Initiate appropriate referrals and outreach to PCP, specialists and health plans. Compose visit summary portion of provider letter.
- Achieve clinical performance targets. Accurately complete assessments and achieve target quality metrics.
- Monitor and perform follow-up with providers and clinics for completion of Annual Wellness Assessments and medical records, and provides education, training and support as needed to these offices.
- Participate in all mandatory compliance and other training programs, seek guidance for compliance-related concerns and adhere to all applicable laws and regulations including but not limited to, OSHA, CLIA, State Board of Nursing and Federal DEA Board of regulations.
- Assist in the development and preparation of PCP/specialist/patient education materials, guidelines a

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