ComplexCare Solutions (CCS) is seeking Nurse Practitioners and Physician Assistants to conduct home visits to complete annual health risk assessments on health plan members. The assessment includes a detailed medical history and medication review as well as a physical examination to comprehensively document a member's conditions and health status, including the supporting evidence for all medical conditions.
CCS excels at delivering high-touch, high-value assessment and care management services for health plans nationwide. We are known for our successful in-home member engagement, which allows us to collect more robust data, implement personalized care plans, and motivate change for desired member outcomes. Our goal is also to strengthen members’ connections to their regular sites of primary care.
- Perform in-home annual health assessment of high-risk health plan members leading to comprehensive picture of a member’s medical conditions, prior and current medical history, as well as conduct a medication review.
- Provide member education regarding health conditions, medications, and nutrition. Emphasize the importance of consistent monitoring of health needs together with their Primary Care Physician.
- Identify opportunities for preventive care, health promotion, home safety, and illness prevention.
- Complete all documentation within 24 hours from visit.
- Communicate urgent medical needs (including all prescription needs) with the member’s Primary Care Physician. CCS Nurse Practitioners and Physician Assistants are not permitted to prescribe medication per CCS policy.
- Document clinical escalations, i.e., urgent medical or non-urgent care management needs, in accordance CCS policy.
- Communicate clearly and in a timely manner with manager when clinical escalations are encountered.
- Perform, document, and communicate results of in-home Point of Care (POC) Testing when directed.
- Be responsive to CCS managers and directives (policies) and comply with trainings and updates as mandated by CCS.
- Maintain ongoing Continuing Education as mandated by state licensure. Maintain strong professional level of knowledge and comprehensive clinical assessment skills related to chronic disease documentation including the following:
- Knowledge of CMS Regulations and NCQA HEDIS Guidelines;
- Knowledge of Evidence-based Clinical Practice Standards: American Diabetes Association (ADA), American College of Cardiology (ACC), American Heart Association (AHA)
- Familiarity with ICD-10 and CPT coding practices.
Advanced practice degree and active (current) Nurse Practitioner (or PA) licensure in the state where services are being provided
Nurse Practitioner and Physician Assistant Board certification required
Maintains current CPR certification (ACLS, BLS - Provider, CPR - Provider or ATLS)
Strong professional level of knowledge and comprehensive clinical assessment skills in the adult population and chronic disease management
Excellent computer skills - familiar with Microsoft Office or experience using an electronic medical record and comfortable utilizing a tablet to document
Excellent customer service skills
Per Diem Availability – 25 hour slots of availability required per month (not inclusive of travel time between appointments)