Family Medicine Nurse Practitioner

Position Summary:

The Population Health Advanced Practice Provider (APP) Manager delivers high-quality, patient-centered care through direct, billable clinical services while supporting population health and value-based care initiatives. This role performs comprehensive medical evaluations, diagnoses and treats acute and chronic conditions, closes care gaps, and supports risk adjustment and quality outcomes. The APP Manager also provides clinical leadership and collaboration within interdisciplinary care teams to improve patient outcomes, reduce avoidable utilization, and support organizational performance under value-based contracts.

Duties and Responsibilities:

Direct Clinical Care & Billable Services:

· Perform comprehensive, billable patient visits in virtual, clinic, or community-based settings, including:

o Annual Wellness Visits (AWVs)

o Chronic Care Management (CCM)

o Transitional Care Management (TCM)

o Primary care and follow-up visits

· Conduct complete medical histories, physical exams, and risk assessments.

· Diagnose and manage acute and chronic conditions within scope of practice.

· Order, interpret, and follow up on diagnostic tests and labs.

· Prescribe medications and treatments in accordance with state law, protocols, and collaborative agreements.

· Refer patients to specialists or supervising physicians when clinical needs exceed scope.

· Provide health education, preventive counseling, and self-management support to patients and caregivers.

Population Health & Value-Based Care Activities:

· Identify, document, and accurately code chronic conditions (HCC/RAF) to support risk adjustment and appropriate reimbursement.

· Close gaps in care related to preventive screenings, immunizations, and chronic disease management.

· Develop and implement individualized, longitudinal care plans in collaboration with patients and care teams.

· Utilize population health data, registries, and dashboards to prioritize high-risk patients.

· Support achievement of quality benchmarks, including HEDIS, STAR measures, UDS-related measures, and payer-driven metrics.

· Contribute to reducing hospital admissions, readmissions, and emergency department utilization.

Care Coordination & Interdisciplinary Collaboration:

· Collaborate closely with physicians, clinical pharmacists, nurses, case managers, social workers, and community partners.

· Participate in interdisciplinary team meetings, case conferences, and care planning discussions.

· Communicate effectively with health plans, payers, hospitals, and post-acute providers to ensure continuity of care.

· Support transitions of care and timely post-discharge follow-up.

Clinical Leadership, Oversight & Quality Improvement:

· Provide direct supervision, clinical guidance, mentorship, and support to APPs, licensed, and unlicensed population health staff as assigned.

· Assist with onboarding and training related to workflows, documentation standards, and value-based care principles.

· Participate in performance improvement (PI) and quality improvement initiatives.

· Contribute clinical insight to workflow optimization and care delivery model development.

· Participate in payer meetings or internal reviews related to quality, utilization, and performance outcomes.

Documentation, Compliance & Professional Practice:

· Ensure timely, accurate, and compliant documentation in the EHR to support billing, quality reporting, and regulatory requirements.

· Maintain licensure, certification, prescriptive authority, CPR certification, and credentialing requirements.

· Adhere to organizational policies, HRSA/FQHC standards, and scope-of-practice regulations.

· Demonstrate flexibility and adaptability to meet changing organizational and patient needs.

· Perform other duties as assigned by Population Health or Clinical Leadership.

Comprehensive Benefits Package includes: Paid Time Off, Paid Holidays, CME allowance with paid days off. Medical, Vision, Dental, Short and Long Term Disability, and Life Insurance. Retirement plans to include 457 and 401(k). Great Electronic Medical Record System.