Clinical Nurse Practitioner (Houston, TX)
Devoted Medical Group
A bit about us:
We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being.
That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly.
We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.
A bit more about this role:
This position represents an amazing opportunity for a caring nurse practitioner (NP) with an entrepreneurial streak. As an inaugural NP of Devoted Medical Group (DMG), you’ll be helping to deliver world-class health care —from the studs up. You will play an integral role in helping to build and staff a house call medical practice focused on delivering multiple different clinical services, including: i) home-based wellness visits designed to screen for new medical problems, deliver evidence-based chronic disease care, and help Devoted Health Plan to achieve 5 star performance as a Medicare Advantage health plan; ii) longitudinal home-care for home-bound, medically complex frail elderly members of our health plan; and iii) post-discharge home visits, phone calls, and coaching as part of a readmissions reduction program offered to Devoted Health members who were recently discharged from the hospital.
On a day-to-day basis, you’ll be responsible for performing home-based annual wellness visits, routine and urgent house calls for home-bound frail elders, and delivering post-discharge care through DMG’s readmissions reduction program. You will also work with DMG’s physician and house call team to coordinate care for these patients, and support relationships with local and regional primary care physicians, specialists, and health systems. Furthermore, you will help design a scalable operating model for the house call practice, and think creatively about the best ways to deliver the highest quality care. You and your DMG colleagues will also work to identify and troubleshoot barriers to delivering outstanding, high-value care, and to expand access to the services that you deliver through this house call practice. You will play a central role in synthesizing what you learn about how to deliver outstanding home-based clinical care, and sharing this learning with Devoted Health’s clinical leadership in Waltham, Massachusetts. At the same time, we will help and support you to learn, and gain the knowledge and experience that you need to achieve your career development goals, which might include growing your career into more senior levels of leadership at a payer or provider organization.
Responsibilities will include:
- Conducting home visits and phone calls to Texas elders in need of home care. There will be three primary types of visits
- Providing high quality home-based care for medically complex frail elders
- Supporting recently hospitalized members as they transition home by performing post-discharge home visits and phone calls to reconcile medications, assess members’ clinical status, and ensure that they have access to all necessary home services
- Perform home-based Annual Wellness Visits for members, which will include comprehensive assessments of member’s health and clinical problems, identification of Healthcare Effectiveness Data and Information Set (HEDIS) measures that the member qualifies for, and to close HEDIS gaps, and following up on any new issues identified
- Excellent patient care
- Supporting and coaching members to improve management of their chronic condition(s), and to optimize adherence with medications and care plans
- Using clinical data and observations to understand the member’s needs and how to meet them
- Applying knowledge to suggest safe exercise routines, dietary plans, meditation or stress reduction techniques
- Explaining complicated medical terms in plain language
- Educating the member on appropriate care and settings based upon their healthcare needs
- Communicating with patients by tele-medicine
- Continuously evaluating the member’s progress in meeting their goals
- Supporting members in understanding diagnostic tests and treatments, including costs, risks, and alternatives so they can make an informed decision about their care needs
- Preparing members for their inpatient and outpatient treatments and coordinate any care needed post-treatment
- Working closely with other members of the patient’s care team including their PCP, specialists, hospital physicians, other Devoted team members, and family members and caregivers
- Collaborating with our PCP partners, including by: getting information about patients, making sure services are helpful and additive to PCP care, consulting on key decisions, and sharing information from care provided back to PCPs to improve future care
- Visiting members in the hospital as they approach discharge in order to ensure a smooth transition
- Developing care plans collaboratively with the member and their caregivers
- Working closely with Devoted Clinical Guides, nurses working in Waltham that provide clinical guidance to members in addition to Care Management, Case Management, Disease Management, and Utilization Management
- Working closely with Devoted Local Service Guides, member-facing service representatives who will meet members in their home to, among other things, identify community-based resources for social determinants and other needs
Attributes to success:
- A NP licensed to practice in Texas with 5 or more years working in outpatient clinical practice
- Significant experience performing house calls and caring for Medicare patients
- Experience in primary care, family medicine, geriatrics, or palliative care
- Expertise in taking a thorough medical history and performing a comprehensive physical exam
- Significant experience managing medically complex patients with acute illnesses in their homes
- Experience with recognizing interventions to improve population health (i.e. readmissions reduction, quality improvement programs)
- A deep understanding of managed care, including how to appropriately assess for HEDIS measures, code clinical comorbidities, and identify clinical care gaps
- A strong desire to continue to practice clinical nursing and perform house calls - you think more of our care should be performed this way
- Extra interest in bilingual Spanish speakers or strong cultural competencies across a range of cultures
Desired skills and experience:
- Ability to work in a startup, fast paced environment
- You have great clinical and non-clinical judgment
- You love caring for complex patients in their homes; getting the sickest patients “on track” just makes you so happy
- You are deeply empathetic and humanistic, and want to go the last mile for your patients
- You know what you do and don’t know, and understand that asking for help when you need it is a sign of strength
- You care about building a caring, supportive, operationally rigorous environment, and have lots of practical ideas about how to make a great home-care service experience
- You learn from every experience and are not afraid to fail - that's how you're wired
- You have a passion for making healthcare better, solving complex problems, and supporting the delivery of healthcare that we would want for our own family members
- You enjoy a fast-paced, high-energy, growing organization
- Agility and collaboration are critical to your success - we are a new organization and have a start-up mentality
If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you!
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.