Description
Background/Description:
CMS ACCESS program- it is a new program based on driving clinical outcomes across different tracks (risks/diagnosis). This program focuses on the cardiometobolic track.
Initial Visits: NPs would conduct initial visits on referred pts to drive outcomes and goals
Looks at history, home monitoring, orders labs (most often lab protocol including A1C, lipids, CBC, and urine microalbumin) and makes recommendations
Ideally review confirmed dx, review what’s been tried and has been successful/unsuccessful, review treatment goals with pt, recs back to referring provider
Responsibilities:
Conduct synchronous and async telehealth patient visits to assess patients with chronic diseases such as hypertension, dyslipidemia, diabetes, obesity, and early stage kidney disease
Order lab tests and other diagnostics as needed to assess the status of chronic conditions
Provide treatment recommendations back to the referring provider
Review and respond to remote patient monitoring (RPM) data, lab results, vital signs, and patient reported symptoms
Prescribe and optimize patient medical therapy according to clinical practice and evidence based guidelines for patients not meeting clinical outcomes targets
Achieve clinical outcomes and KPIs for a panel of patients
Serve as the interface between the patients and others in the healthcare system, including providers, clinics, pharmacies, etc.
Support the internal growth of clinical programs in a fast paced and dynamic team environment
Participate in program building and operational workflows during growth and implementation phases
Requirements
Minimum Qualifications:
Minimum 3+ years of experience treating patients with cardiovascular/ cardiometabolic/ cardiorenal diagnoses, diabetes and/or obesity in an outpatient setting
Completion of an accredited graduate-level Advanced Practice Registered Nurse (APRN) program
National certification as an APRN with an adult or family focus
Current enrollment as a Medicare Part B provider
Prior experience working in digital health and remote/virtual patient management Proficient in using electronic health records and other healthcare IT systems
Passion for helping patients improve cardiovascular health through the application of clinical practice guidelines and evidence based medicine
Interested in implementing technology to improve healthcare and able to quickly learn and use new software and tools
Be resilient to function in a dynamic environment with an ability to problem solve
Commitment to providing high-quality care and improving patient outcomes.
Strong customer service skills, with ability to identify hurdles and formulate solutions
Proven ability to think critically and make decisions under pressure
Ability to handle conflict resolution and remain tolerant/flexible in all situations
High-speed home internet access
Quiet home office space, free of distractions
