Advanced Practice Clinician, Integrated Care Delivery (San Bernardino County

Responsibilities

• Provide and coordinate primary care to an assigned panel of SCAN members in their place of residence (senior living communities or skilled nursing facilities).
• Conduct physical/wellness examinations, assessments, and occasionally urgent medical visits; provide telephonic triage to ensure timely, appropriate care and hospital avoidance.
• Administer vaccines and order/interpret diagnostic tests.
• Initiate goals‑of‑care conversations with patients, families, and living‑community staff and manage chronic disease treatment plans.
• Identify patient health‑care needs and develop comprehensive care plans, collaborating with case management for timely access to necessary services.
• Manage visitation schedules in line with established practice protocols and adjust based on members’ needs and acuity.
• Engage with primary care physicians and other health‑care professionals in collaborative relationships aimed at disease prevention, health promotion, and chronic disease management.
• Partner closely with primary care physicians for clinical oversight and guidance.
• Connect with specialists, hospitals, ancillary care providers, and community‑based organizations to ensure continuity of care, promote shared decision‑making, and advocate for members.
• Actively monitor and address clinical quality gaps in partnership with other providers.
• Document member visits and interactions promptly, following practice protocols.
• Serve as a direct resource for members, families, community staff, and support personnel.
• Participate with the Integrated Care Sales team in events to build member awareness and educate communities.
• Initiate and complete virtual health visits to promote accurate triaging and reduce travel time.
• Participate in the on‑call program available to members after hours and on weekends.
• Maintain professional and technical knowledge by attending educational workshops and reviewing professional publications.
• Contribute to team efforts to meet quality healthcare goals by closing care gaps, attending high‑risk group discussions, and optimizing clinical workflows and protocols.
• Other duties as assigned.

• Master’s degree in Nurse Practitioner Certificate or Master’s from an accredited Physician Assistant program; education in adult/geriatric medical care preferred.
• Current California Nurse Practitioner license or California Physician Assistant Certification (PA‑C) in good standing.
• Wound Care Certificate and Palliative Care Certificate – a plus.
• Knowledge of treatment of complex chronic diseases, such as dementia, diabetes, heart failure, and COPD.
• Ability to identify health‑care needs and refer and coordinate with other resources/programs appropriately.
• Knowledge of HCC and ICD‑10 coding and documentation.
• Knowledge of wound care and management.
• Knowledge of CMS guidelines and Medicare Advantage Managed Care.
• Comfortable initiating goals‑of‑care and end‑of‑life discussions.
• Strong interpersonal skills and a change‑agent mindset for building relationships with health‑care teams and patients.
• Knowledge of and ability to maintain HIPAA requirements.
• Adaptable and open to change and problem‑solving.
• Basic technological proficiency (Word, Excel, PowerPoint, Outlook, EMR) and openness to new technology.
• Physical ability to stoop, kneel, crouch, bend, reach, lift, pull, push, and carry up to 10lbs regularly and up to 50lbs occasionally.
• Multilingual/multicultural capability – a plus.
• Travel (75%+ of time in the assigned area); must have a valid driver’s license, automobile insurance, and reliable transportation.

• Base salary range: $ to $ annually.
• Quarterly bonus program.
• Robust wellness program.
• Generous paid‑time‑off (PTO).
• Eleven paid holidays per year, plus one additional floating holiday.
• 401(k) retirement savings plan with employer match and contribution.
• Robust employee recognition program.
• Tuition reimbursement.

To ensure the health and safety of our members, job offer with SCAN is contingent on providing proof of a recent tuberculosis screening upon hire or proof of a negative screening within the last year.

SCAN is a proud Equal Employment Opportunity and…