Nurse Practitioner OR Physician Assistant

As a HG, you will perform a whole-person clinical assessments, including:

• Assessing both behavioral and physical health conditions with a thorough history and physical examination
• Verifying previously diagnosed conditions and capturing conditions not yet diagnosed based on review of medical records, evidence-based practice, clinical judgment and diagnostic studies. ,
• Overseeing transitions of care by conducting post-hospital discharge visits to ensure a stabilizing plan is in place to avoid unnecessary rehospitalizations.
• Conducting visits in the in the office, virtually, in the field, or in an individual’s home when needed
• Ensuring continuity of care, referring to community primary and behavioral health providers and specialists based on assessed needs
• Supporting individuals in developing and exercising self management skills and person-centered care around their individual goals and preferences via motivational interviewing and holistic care planning
• Organizing clinical information in a manner that supports appropriate clinical documentation criteria for successful disability applications (if appropriate)
• Collaborating with a team of clinical documentation specialists, certified coders, and medical assistants

As a HG, you will lead the medical component of the team-based care provided by firsthand, including:

• Training and advising roles like Medical Assistants, and Peer Recovery Specialists on behavioral, clinical, and social health priorities
• Supporting care coordination
• Leading care and disease management and identifying actionable care gaps
• Communicating and coordinating with individuals’ care providers, primarily at CMHCs, FQHCs, and hospitals
• Providing direct patient care when unscheduled care needs cannot be met by existing community providers

As a HG, you will collaborate with other team members to provide integrated care:

• Assist firsthand Guides (peer specialists) with engagement and recovery support
• Work with the firsthand Care Team and the Community Resources Guide in supporting individuals’, SDOH needs and with medical eligibility assessments for disability applications.

You will be a good fit if you have:

• Excellent clinical acumen in outpatient chronic disease and behavioral health care
• Empathy, compassion, and approachability
• Excellent listening, communication, and interpersonal skills
• Desire to help people in need and support their path to wellness
• Comfort working as part of a multidisciplinary team, and enjoy mixed roles and duties – this is a mix of direct service, teaching, and care management
• Cultural humility, knowledge of trauma informed care, and social determinants of health
• Desire to perform data driven care
• Familiarity with local providers
• Ability to maintain professional boundaries and engagement skills with a population with challenges and in non-traditional work conditions
• Intermediate computer and typing proficiency – experience with Electronic Health Records, familiarity with Google Suite a plus
• Ability to operate a vehicle, including a driver’s license that is active and in good standing; must be eligible to drive under Company insurance policy

The experience you bring to the role includes:

• 5+ years clinical care as a Nurse Practitioner or Physician Assistant, ideally in a primary care setting
• Working with and managing a population with challenges such as behavioral health and/or SUD conditions
• Developing and delivering educational programs to nurses and affiliated medical staff
• Care management and coordination experience.