Advanced Practice Registered Nurses / Physician Assistants
Population Health Advanced Practice Professional NP/PA
Benefits Offered Vision, Medical, Life Insurance, 401k, Dental
Employment Type Full-Time
Position Overview: The Population Health Team at CAREMOUNT MEDICAL develops and executes clinical programming designed to enhance clinical quality outcomes and promote a reduction of utilization costs of care for our most vulnerable and high risk patients. The Population Health APP empowers patients to actively participate in improving their own healthcare through personalized care plans that targets each patient’s specific healthcare issues and needs. The Population Health APP role is focused on providing clinical care to designated patient populations who may not have an active relationship with a Primary Care Physician but have identified healthcare needs associated with multiple co-morbidities or identified gaps in care. The Population Health APP, in partnership with our Care Coordination department, performs essential, proactive, patient centered care to patients, caregivers and their families. The Population Health APP is an integral part of CAREMOUNT MEDICAL care team and our approach to delivery of patient-centered, compassionate medical care, complementing the necessary professional services to patients.
Essential Duties and Responsibilities (including but not limited to the following):
The Population Health APP is an integral member of the direct delivery care team, and serves as a gateway to information and support for designated patient populations.
The Population Health APP performs review of laboratory and point of care results, received from payer partner programming, and develops individualized care plans as appropriate. Included in the care plan development is patient education and assessment for rising risk factors as well as identification of existing gaps in care.
The Population Health APP facilitates communication between specialists and Primary Care Physicians for development of cohesive care plan, communicating action items to all responsible parties and following up to completion of same. Assist in establishment of a PCP relationship with CareMount Medical Physician.
The Population Health APP utilizes tools and documents that support a guided care process, collaborating with patients/families/Physicians and other members of the care team toward an effective plan of care, including:
a) Assess patient and family’s unmet health and social needs b) Provide effective communications to improve health literacy c) Develop a care plan based on mutual goals with patient, family and provider’s emergency plan, medical summary and ongoing action plan, as appropriate. Monitor patient’s adherence to plan of care and progress toward goals in timely fashion, facilitate changes as needed. d) Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
The Population Health APP ensures effective tracking of test results, medication management and adherence to follow-up appointments of assigned patients.
The Population Health APP performs Physical Assessments, Annual Wellness Examinations and other clinical services at assigned locations (ie CareMount Medical Office, SNF, Patient home, etc) to enhance development and adherence to Care Plan goals and directives.
The Population Health APP provide clinical program support to Care Coordination activities and programs and participates in Care Coordination related training and meeting activities.
The Population Health APP performs in home health assessments and evaluations for our chronically ill population as directed.
Qualifications and Education:
Must be a Licensed Practical Nurse Practitioner or Physician Assistant in New York State
3-5 years’ experience in clinical or community health settings, preferred
Previous experience in caring for chronic disease patients and/or experience in Geriatrics, preferred
Experience with navigation of local medical and social support systems.
Previous experience with Electronic Medical Records and preferred.
Must be willing to travel within the CareMount Medical practice locations geography.
Knowledge, Skills and Abilities:
Knowledge of community health services and willingness to develop and foster relationships with community resources of direct value to CareMount Medical patients and care team.
Strong organizational skills and demonstrated the ability to maintain accurate notes and records.
Strong interpersonal skills and an understanding and commitment to delivery of patient centered medical care with a team-based approach
Ability to work independently, exercise creativity, is attentive to detail.
Ability to manage multiple and simultaneous responsibilities and to priorities scheduling of work autonomously
All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer – M/F/Veteran/Disability
Caremount Medical - Clinical
Why Work Here?
New York's largest, physician-owned, multi specialty group.
CareMount Medical, P.C. is the largest independent multispecialty medical group in New York State, providing comprehensive medical care of the highest quality to over 640,000 patients in more than 45 locations throughout Westchester, Putnam, Dutchess, Columbia, and Ulster counties and New York City. Founded in 1946 as Mount Kisco Medical Group, CareMount has grown to over 600 physicians and advanced practice professionals representing more than 40 different medical specialties. CareMount is affiliated with world-class organizations including Massachusetts General Hospital, Mount Sinai Health System, and Memorial Sloan Kettering Cancer Center. CareMount offers on-site laboratory and radiology services, endoscopy and infusion suites, and operates eight urgent-care centers. Our physicians are frequently recognized as best doctors in respected publications and have been featured in lists including New York Magazine’s “Best Doctors,” Westchester and Hudson Valley Magazine’s “Top Doctors” as well as in Castle Connolly Medical’s “Top Doctors.” For additional information about CareMount Medical and its specialties, please visit: www.caremountmedical.com. CareMount Medical is a registered service mark of CareMount Medical P.C.
CareMount Medical is the largest, independent multi-specialty medical group in New York State. CareMount Medical provides the highest quality medical care in over 40 different locations throughout Westchester, Putnam, Dutchess, Columbia and Ulster counties. We provide medical care to over 500,000 patients in 43 different locations.Founded in 1946, CareMount Medical has grown to 560 physicians representing 43 different medical specialties with major campuses in:Mount KiscoCarmelKatonahKingstonFishkillJefferson ValleyPoughkeepsieRhinebeck