Advanced Practice Provider - Pittsburgh, PA

JOB SUMMARY

This is a full‑time community‑based position requiring frequent travel within the assigned territory in Pittsburgh, PA. A significant portion of this role involves conducting comprehensive health risk assessments directly with members in their homes. This role is integral to the organization’s comprehensive care delivery system. The incumbent delivers high‑quality, patient‑centered care through in‑home, virtual, and telephonic comprehensive clinical assessments for members with chronic health conditions.

This autonomous position provides holistic, community‑based care, especially for geriatric and palliative populations. The role proactively manages symptoms, guides advance care planning, and supports members with chronic or life‑limiting illnesses to ensure optimal quality of life and health outcomes. The role involves accurately identifying and documenting all active chronic medical conditions essential for risk adjustment.

• Conduct comprehensive in‑home, video, and telephonic clinical assessments, including detailed histories, physical examinations, and identification of all active diagnoses, symptoms, functional status, and social determinants of health.
• Order and interpret laboratory, radiological, and other diagnostic studies, then make medical diagnoses and institute appropriate therapy within applicable scope and standards of practice.
• Manage medications and treatments related to palliative care, alleviating pain and other distressing symptoms related to life‑limiting illnesses.
• Provide emotional and psychological support, and educate patients and families about illness progression, treatment options, and aligning to goals of care.
• Facilitate advance care planning conversations and end‑of‑life discussions.
• Collaborate and coordinate care with other providers active on the patient’s care team and participate in interdisciplinary team meetings to review and update patient care plans.
• Institute emergency measures or appropriate stabilization for acute patient situations.
• Utilize electronic medical record (EMR) systems for thorough and compliant clinical documentation, ensuring timely and accurate record of pertinent information to support comprehensive medical coding and risk adjustment methodologies.
• Identify and inform the attending physician of record of all significant changes to the patient’s ongoing condition in a timely manner.
• Maintain mandatory professional continuing education and uphold professional practice consistent with organizational statements and medical staff compliance.
• Other duties as assigned or requested.

• Graduate from an accredited PA program OR Graduate from a Nursing Approved Master’s or Post Master’s program.

• None.

• Board certification or clinical experience in a relevant specialty (e.g., Family Medicine, Internal Medicine, Geriatrics, Hospice or Palliative Care).

• 3 years of clinical experience as an NP or PA, preferably in primary care, geriatrics, palliative or hospice care, chronic disease management, home health, or a similar community‑based setting.

• Previous experience conducting in‑home assessments or house calls.
• Knowledge of CMS regulations and guidelines.
• Experience in population health management.

• CPR Certification.
• Current Physician Assistant License OR Current State of PA RN licensure or Current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC) + CRNP license and Prescriptive Authority in the State of PA.
• Valid driver’s license and reliable transportation with appropriate insurance coverage to travel to patient homes across designated service areas.

• DEA controlled substances license.

• Patient & Family Engagement:
  Exceptional communication, motivational interviewing and empathy skills for patient‑centered care, sensitive health discussions, and effective education for diverse patient populations.
• Clinical Acumen & Care Planning:
  Expertise in critical clinical assessment and the ability to identify and address patient care gaps, opportunities for health improvement and formulate care plans including advance…