Job Description
In this role you work as a provider member within the HBMC interdisciplinary team in the direct delivery of home-based medical care of a population within an assigned geography. Dedicated to improving the health and well- being of patients, this position collaborates with the PCP, HBMC interdisciplinary teammates and consultants, and as needed, the health plan Medical Director and other health professionals, to develop and carry out patients' goals of care in all phases of the patient journey. This is a Monday-Friday, days position with some rotating on call responsibilities. In this position you will be traveling to the home setting throughout greater Detroit, MI area - several openings. Primary Responsibilities: Conduct in-home assessments on health plan members, including past medical history, review of symptoms, physical examination, medication review and depression screening Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initial comprehensive assessment on all newly enrolled patients and provides ongoing care thereafter. Develops a patient management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with patients and/or their legal representatives to review newly developed or modified care plans; involves the PCP or supervising physician in these meetings, when applicable Completes follow-up and post-discharge assessments according to documented standard operating procedure Prescribes appropriate diagnostics and interventions to avoid unnecessary acute admissions Comfortable with basic pr