The Community Based Advanced Practice Provider focuses on providing both urgent and primary care to our members where they live. Working in partnership with the members primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.

Duties and Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges
• Work closely with the transitional care manager and the members primary care team, following through on the discharge plan with the member.
• Conduct patient/member...