Community Health FNP: Telehealth & Field Care in NYC

Community Health Family Nurse PractitionerNew York City, NYSalary range: $135,000 - $150, 000/yearAbout Vanna Health

Vanna Health focuses on reimagining care for individuals with chronic health challenges. Our goal is to empower these individuals to lead healthy and meaningful lives by providing social, physical and mental healthcare support and connecting members to community programs. Our technology-enabled approach, developed by our own team of engineers and designers, ensures our staff and members are well supported.

Vanna delivers in-person and virtual community-based engagement through an interdisciplinary team of coaches and clinicians. We leverage partnerships with existing community resources to facilitate support networks unique to an individual’s needs and location - connecting them to established psychosocial rehabilitation programs, resources for housing, transportation, etc. and various digital engagement opportunities to address members’ needs.

Vanna Health is seeking an experienced, recovery-focused Family Nurse Practitioner (FNP) who is passionate about community care, health education and facilitating care that addresses all the dimensions of wellbeing. In this role, you will bring passion for serving individuals with mental illness and chronic physical health conditions, helping them access community-based care to improve health outcomes and quality of care for individuals in the New York City area.

This role focuses on conducting timely follow-up visits within 1 week of discharge from the emergency department (ED) or inpatient setting either in-person in the field or via telehealth, with the goal of reducing 30-day readmissions and ED re-presentations. The FNP will support member medication adherence through education, medication reconciliation and providing bridge prescriptions as needed. The FNP will also address barriers to care access, and will initiate or adjust medications for members experiencing challenges engaging with community providers.

The role includes offering same-day urgent visits to help avoid unnecessary ED utilization, optimizing chronic disease management for high utilizers with complex conditions, facilitating preventive care and participating in complex case reviews. The FNP will play a key role in care coordination, working closely with Vanna Health’s interdisciplinary team to ensure continuity of care, address medical and behavioral health needs, and support engagement with outpatient services.

Deliver direct clinical care in-person in the community, including member homes or via telehealth, including:

• Conduct post-discharge follow-up visits within 7 days for eligible members

• Perform comprehensive clinical assessments, including medical and behavioral health needs

• Conduct annual wellness visits for eligible members

• Prescribe and administer long-acting antipsychotic medications and monitoring of vital signs

• Conduct specified point-of-care screening and laboratory testing

• Develop and implement care plans in collaboration with an interdisciplinary team

• Coordinate care with internal team members, including RNs, physicians, coaches, community health workers, and peer specialists

• Liaise with external outpatient providers and payer care managers to ensure continuity of care and appropriate follow-up

• Identify and address barriers to care, including social determinants of health

• Support efforts to reduce 30-day ED re-visits and hospital readmissions

• Ensure members are up to date on preventive care and screenings (e.g., breast cancer screening, annual eye exams for members with Diabetes Mellitus, Diabetes screening for members taking antipsychotic medication, colorectal cancer screening)

• Document all encounters and care coordination…