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