Quality Community Based Advanced Practice Provider

Absolute Care is a value-based care organization serving high-risk Medicaid and Medicare populations across Ohio. We go Beyond Medicine to deliver whole‑person care through interdisciplinary teams embedded in the communities we serve. The CKD CBP role is central to our mission of slowing disease progression, reducing avoidable hospitalizations, and meeting members where they are—literally.

This role is primarily community‑based, focusing on providing annual wellness visits to Absolute Care's community members in their homes. The annual wellness visits are conducted for the purpose of risk adjustment and quality gap closure, with an emphasis on clinical documentation excellence—ensuring every chronic condition is documented with the specificity and clinical detail required for accurate risk adjustment. Most visits will be conducted in the member's home;

visits may occasionally take place in the provider's home center. Upon mutual agreement, the provider may also work in the intermediate care area of their home center.

• Perform community‑based annual wellness visits in member homes as scheduled by the Absolute Care team.
• During scheduled hours without visits on the calendar, proactively contact members by phone to schedule and arrange upcoming annual wellness visits.
• Conduct comprehensive member assessments including Health Risk Assessment (HRA), depression screening (PHQ‑2/PHQ‑9), cognitive screening, functional status/ADLs, fall risk assessment, and advance care planning.
• Perform comprehensive medication reconciliation for adherence and appropriateness; review external prescription history.
• Provide member and family education on chronic disease self‑management, preventive care, and available Absolute Care resources.
• Communicate the benefits of Absolute Care to the member and coordinate care with the center if desired.

• Complete a detailed assessment and plan for each of the member's chronic conditions using the DSP framework (Diagnosis with specificity → Status → Plan) to support accurate risk adjustment and HCC capture.
• Ensure annual recapture of all active HCCs with appropriate ICD‑10 specificity and supporting clinical evidence (e.g., CKD stage, diabetic complications, heart failure type/class).
• Review diagnoses against the member's medication list to identify documentation opportunities and ensure clinical consistency (e.g., medications present without a supporting diagnosis, or diagnoses without an active treatment plan).
• Query the member's history for conditions that may be under documented or uncaptured, including SDOH needs.

• Identify and address open quality care gaps during each visit (e.g., A1c testing, breast cancer screening, diabetic eye exams, blood pressure control) using PRISMA and pre‑visit chart prep data.
• Ensure the correct AWV type is documented (Initial vs. Subsequent) and the appropriate AWV workflow/template is used in eCW.
• Document a preventive care plan and 5–10 year screening schedule, or reference it in patient instructions.
• Review and update the member's care team (PCP, specialists, care coordination, community supports).

• Communicate member's medical conditions, mental health conditions, substance use, and SDOH needs to Absolute Care resources as discussed and agreed upon with the member.
• Offer intervention to at‑risk members to avoid unnecessary hospitalizations.
• Coordinate with the center‑based care team, CHWs, and community transitional care managers when member needs are identified during visits.
• Document appropriately in the Electronic Medical Record within required time frames.

• Upon mutual agreement, provide clinical services in the intermediate care area of the home center, supporting acute and episodic care needs as they arise.

• Physician, Nurse Practitioner, or Physician Assistant with 2 or more years’ experience.
• Active, unrestricted state license and DEA; board certification (AANP, ANCC, or NCCPA).
• Valid driver's license and reliable transportation—this role…