Duties and Responsibilities:
Direct Clinical Care & Billable Services:
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Perform comprehensive, billable patient visits in virtual, clinic, or community-based settings, including:
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Annual Wellness Visits (AWVs)
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Chronic Care Management (CCM)
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Transitional Care Management (TCM)
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Primary care and follow-up visits
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Conduct complete medical histories, physical exams, and risk assessments.
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Diagnose and manage acute and chronic conditions within scope of practice.
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Order, interpret, and follow up on diagnostic tests and labs.
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Prescribe medications and treatments in accordance with state law, protocols, and collaborative agreements.
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Refer patients to specialists or supervising physicians when clinical needs exceed scope.
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Provide health education, preventive counseling, and self-management support to patients and caregivers.
Population Health & Value-Based Care Activities:
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Identify, document, and accurately code chronic conditions (HCC/RAF) to support risk adjustment and appropriate reimbursement.
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Close gaps in care related to preventive screenings, immunizations, and chronic disease management.
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Develop and implement individualized, longitudinal care plans in collaboration with patients and care teams.
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Utilize population health data, registries, and dashboards to prioritize high-risk patients.
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Support achievement of quality benchmarks, including HEDIS, STAR measures, UDS-related measures, and payer-driven metrics.
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Contribute to reducing hospital admissions, readmissions, and emergency department utilization.
Care Coordination & Interdisciplinary Collaboration:
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Collaborate closely with physicians, clinical pharmacists, nurses, case managers, social workers, and community partners.
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Participate in interdisciplinary team meetings, case conferences, and care planning discussions.
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Communicate effectively with health plans, payers, hospitals, and post-acute providers to ensure continuity of care.
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Support transitions of care and timely post-discharge follow-up.
Clinical Leadership, Oversight & Quality Improvement:
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Provide direct supervision, clinical guidance, mentorship, and support to APPs, licensed, and unlicensed population health staff as assigned.
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Assist with onboarding and training related to workflows, documentation standards, and value-based care principles.
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Participate in performance improvement (PI) and quality improvement initiatives.
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Contribute clinical insight to workflow optimization and care delivery model development.
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Participate in payer meetings or internal reviews related to quality, utilization, and performance outcomes.
Documentation, Compliance & Professional Practice:
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Ensure timely, accurate, and compliant documentation in the EHR to support billing, quality reporting, and regulatory requirements.
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Maintain licensure, certification, prescriptive authority, CPR certification, and credentialing requirements.
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Adhere to organizational policies, HRSA/FQHC standards, and scope-of-practice regulations.
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Demonstrate flexibility and adaptability to meet changing organizational and patient needs.
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Perform other duties as assigned by Population Health or Clinical Leadership.
Qualifications:
Education & Licensure /Experience:
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Licensed Nurse Practitioner (FNP, AGNP) or Physician Assistant in the State of South Carolina.
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National board certification (FNP-C, AGNP-C, PA-C).
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Master's degree in Nursing or Physician Assistant Studies required.
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Current prescriptive authority and DEA registration.
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Current CPR certification.
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Experience in primary care, family medicine, internal medicine, geriatrics, or population health preferred.
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Experience with AWVs, CCM, TCM, and value-based care visits strongly preferred.
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Knowledge of HCC/RAF coding and quality metrics preferred.
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Prior leadership, mentoring, or supervisory experience preferred.
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Experience working in FQHCs or managed care environments a plus.
