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Rediscover the "joy in practice" while working in a value-based care environment with a team to support you in delivering high quality patient care. Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years.
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Partner with the care team and leverage One Medical Seniors coaching and integrated behavioral health models to engage our geriatric patient population in care and drive behavior change.
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Responsibilities: Provision of compassionate, individualized, and holistic patient care including comprehensive care, urgent care, and chronic condition management that aligns with a patient's goals, value-based care delivery model, reflects appropriate patient risk stratification, integrates with multidisciplinary team services, and identifies and addresses gaps in care.
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Care patients, contribute to a value-based care model, and work with a motivated multi-disciplinary team. Work with Care Navigators (CNs) to provide monthly Chronic Care Management (CCM) visits and.
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Strong understanding of Patient-Centered Medical Home (PCMH) principles and value-based care. Perform chronic care management for patients with conditions such as hypertension, diabetes, and asthma.
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Together, we look to deliver exceptional health care to more consumers, employers, care team members, and health networks to achieve better health outcomes. Our practices offer smaller panel sizes, no billing or coding, and the opportunity to lead systemic change in health care delivery while working with a true team.
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Participate in quality improvement initiatives and value-based care programs. The Primary Care Provider will interact closely with all members of the clinics, including but not limited to, telehealth team members, other Primary Care Providers, and telehealth call center team member, to achieve excellent patient care.
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Provision of compassionate, individualized, and holistic patient care including comprehensive care, urgent care, and chronic condition management that aligns with our value-based care delivery model, reflects appropriate patient risk stratification, integrates with multidisciplinary team services, and identifies and addresses gaps in care.
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By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.
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Partner with the care team and leverage our coaching and integrated behavioral health models to engage our geriatric patient population in care and drive behavior change. The Nurse Practitioner or Physician Assistant will work closely with the medical director to play a critical role in both care delivery and ongoing practice innovation.
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Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders.
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The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. Value-based care, patient-focused and allows you to spend time with those in your care.
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Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology. Participates in the integrated care team meetings.
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Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first. Monogram’s innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum.
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Active and unrestricted Registered Nurse and Nurse Practitioner or Physician Assistant license. Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services.
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care team value based chronic management jobs Title: nurse practitioner in Chagrin-falls, Ohio
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