Atrius Health, an innovative healthcare leader, delivers an effective system of connected care for more than 690,000 adult and pediatric patients at 30 medical practice locations in eastern Massachusetts. Atrius Health’s 645 physicians and primary care providers, along with 420 additional clinicians, work in close collaboration with hospital partners, community specialists and skilled nursing facilities. Our vision is to transform care to improve lives. Atrius Health provides high-quality, patient-centered, coordinated, cost effective care to every patient we serve. By establishing a solid foundation of shared decision making, understanding and trust with each of its patients, Atrius Health enhances their health and enriches their lives. Atrius Health is part of Optum, a health services company focused on building the leading value-based care system in the country. ------------------------------------------------------------------------ *SUMMARY * Under the direction of the department chief, the incumbent is Physician Assistant who travels to patient homes for a majority of their work week using their advanced training/skills in assessing, diagnosing, and treating the patient with both chronic and acute illness and disease. Works in a collaborative team practice that recognizes the patient as the central focus. Serves as a patient educator in areas of specialization. Visits patients with complex health needs who have not engaged with Atrius in accordance with their clinical status. *GENERAL DUTIES AND RESPONSIBILITIES * § Diagnoses and treats acute and chronic illnesses that are of an appropriate level of complexity for the knowledge and experience of the NP. Escalates chronic illness issues to the PCP. § 2-4 days a week the APC will go to visit patient home to provide a point of care (i.e. any non-Atrius off-site location) assessment § Conducts multiple home visits a day for 45-60 minutes § Orders and interprets laboratory work and other diagnostic studies. Develops and implements a plan of care to address the illness, which may include prescribing medications and/or other treatments. May refer patient to subspecialty physicians. § Provides home-based transition of care visits with challenges coming into the office following a hospital or SNF stay § Document timely with an added focus on closing HEDIS quality gap measures and recapturing HCCs § Teaches and counsels individuals and groups about specific health care needs. Serves as an educator in areas of specialization (e.g. family planning, weight loss, smoking cessation). § Develops and implements a comprehensive plan of care for these patients, taking into account social, emotional, and developmental needs, as well as all current medical management practices. § Communicates issues related to patient care with PCP. Collaborates with PCP in provision of patient care. § Participates in department and organizational clinical care initiatives. § Maintains BLS certification. § Performs other duties as assigned. *EDUCATION/LICENSES/CERTIFICATIONS:* Graduate of a State-approved school of Physician Assistant required. Possess a current license to practice in the Commonwealth of Massachusetts, and authorization to practice in the expanded role. Possession and maintenance of or eligibility for DEA and Mass DPH Controlled Substances Registration. American Heart Association Basic Life Support (BLS) required. Advanced Cardiac Life Support (ACLS) may be required based on specialty. *EXPERIENCE:*2 years clinical NP experience in IM, Geriatrics, Primary Care, ED, Urgent Care, or similar setting. Experience with capturing HCCs. Experience with an electronic medical records system, EPIC experience preferred. Experience visiting patients in their homes preferred. *SKILLS:*Must exhibit strong critical thinking, problem solving, interpersonal and good patient interviewing skills. Highly motivated and self-directed. Ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care. Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands. Up to date with current standard of nursing care in Specialty. Demonstrated excellence in practice, documentation, and utilization. Maintain high patient satisfaction. Ability to work effectively as part of a team. Strong computer skills. *OTHER REQUIREMENTS * * Able to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer, and computer applications. * Performs all job functions in compliance with applicable federal, state, local and company policies and procedures. * Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with all Atrius Health and departmental privacy policies, procedures, and protocols. Follows HIPAA privacy guidelines without deviation when handling protected health information. * Access to reliable transportation to conduct patient visits and have a valid U.S. drivers license *WORKING CONDITIONS / PHYSICAL DEMANDS* * Must be comfortable with treating patients out of office and driving in the metropolitan Boston area. ------------------------------------------------------------------------ *_Benefits Include:_* * Up to 8% company retirement contribution, * Generous Paid Time Off * 10 paid holidays, * Paid professional development, * Generous health and welfare benefit package. **Job:** **Clinical Professional* **Organization:** **Chief Medical Office* **Title:** *Physician Assistant / Nurse Practitioner (MNA) - In Home Patient Assessments* **Location:** *Newton MA - Riverside* **Requisition ID:** *123721*