Remote Nurse Practitioner – Mexico or Texas

Location: Remote — Must reside in New Mexico or Texas
Specialty: Primary Care | Telemedicine | Complex Care | Value-Based Care

Help Redefine Care for Complex Patients

An innovative and growing healthcare organization is seekingan experienced Remote Nurse Practitioner to join its expanding clinical team in New Mexico or Texas
.

This is an exciting opportunity for an experienced NP who is passionate about improving outcomes for medically complex patients and wants tomove beyond the traditional, volume-driven clinic environment.

The ideal candidate brings experience in value-basedcare, primary care, telemedicine, longitudinal patient management, and complexcare coordination
, along with strong clinical judgment and a commitment topatient-centered care.

This is primarily a remote, telemedicine-based role
,allowing you to provide high-quality care while helping shape an innovativemodel focused on keeping complex patients healthier and safely supported athome.

You’ll be part of a collaborative, interdisciplinary caremodel that brings together:

• Physicians
• Nurse Practitioners
• Registered Nurses
• Licensed Clinical Social Workers
• Therapists
• Care management professionals
• Otherhealthcare specialists

The team proactively manages the needs of medically complex patients through telehealth, remote care management, longitudinal care, and coordinated clinical support
.

You’ll work closely with patients, families, caregivers,primary care providers, specialists, and health plans to identify needs early,coordinate care, prevent avoidable hospitalizations, and improve overall health outcomes.

The patient population may include Medicaid and Dual Eligible members, including individuals with:

• Complex chronic medical conditions
• Multiple chronic conditions
• Physical disabilities
• Traumatic brain injuries
• Intellectual and developmental disabilities
• Functional limitations
• Medically complex elderly populations

As a Remote Nurse Practitioner, you will play a key role inthe clinical management and coordination of care for medically complex patients.

Responsibilities include:

• Provide clinical care and ongoing patient management through telehealth and remotecare technologies
• Providelongitudinal primary care to assigned patients
• Managemedically complex Medicaid and Dual Eligible populations
• Assess patient needs and develop individualized care plans
• Collaborate with physicians and an interdisciplinary care team
• Coordinate care with patients, families, caregivers, specialists, primary care providers, and health plans
• Identify changes in patient health and intervene early to reduce unnecessaryemergency department visits and hospitalizations
• Support patients during hospital admissions, discharges, and transitions back home
• Participate in advance care planning and goals-of-care discussions
• Participate in shared clinical triage and team-based support
• Support quality initiatives and accurate clinical documentation
• Contribute to HCC coding, risk adjustment, STAR and HEDIS initiatives, and quality-gap closure
• Help develop clinical best practices and improve care delivery processes
• Contribute to the growth and evolution of an innovative value-based care model

• Master'sdegree or higher
• Active Nurse Practitioner license in New Mexico or Texas
• FNP or Adult/Adult-Gerontology Nurse Practitioner certification
• 3+years of recent primary care experience
• 1+year of telemedicine or virtual care experience
• 1+year of longitudinal patient care experience
• 1+year of experience working in a value-based care model
• Experience caring for medically complex adult and/or geriatric populations
• Abilityto practice independently with appropriate prescriptive authority
• Experience with care coordination and complex patient management
• Experience with or understanding of HCC coding and risk adjustment preferred
• Familiarity with STAR and HEDIS quality measures preferred
• Experience with advance care planning and goals-of-care discussions
• Strong clinical judgment and decision-making skills
• Excellent communication