OUTER CAPE HEALTH SERVICES INC

Role Description As a Patient-Centered Medical Home (PCMH), we are committed to providing accessible, high-quality, team-based care. Reporting to the Chief Medical Officer, the Remote Primary Care Access Clinician serves as a vital clinical extension of the interdisciplinary care team, focusing primarily on virtual access and inbox management. By efficiently managing the in-basket and conducting telehealth visits, this role ensures continuity of care, improves patient outcomes, and supports the broader OCHS team-based care model. A typical day consists of approximately 50% telehealth visits with patients and 50% in-basket management and other virtual support. Essential Functions - Serve as a member of the primary care team, providing telehealth and virtual support to an in-person primary care team. - Engage in regular and ongoing communication regarding the health of the population managed. - Utilize EPIC and a range of tools to maximize communication with patients and team members. - Collaborate with the Chief Medical Officer, Senior Medical Director, and nursing staff regarding the daily schedule. - Demonstrate flexibility and willingness to adapt based on daily patient needs. - Keep accurate, complete, legible, and timely medical and other records and files as required by law, which shall become and remain the sole property of OCHS. - Participate in peer review and patient care audits for quality assurance and utilization review to maintain and improve patient standards of excellence. - Maintain knowledge of current developments in specialty to enhance professional expertise, to include keeping current Board Certification and complete CME as needed to maintain licensure. - Maintain a productive and professional working relationship with other clinicians and healthcare professionals within and out OCHS. - Engage respectfully with OCHS administrative and support staff. - Perform care in accordance with all applicable state and federal laws, professional standards, and OCHS policies and procedures. - Other related duties and projects as assigned. Core Competencies / Core Clinical Competencies - Provide patient care that is compassionate, appropriate, and effective for the treatment of and promotion of health. - Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. - Investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve patient care practices. - Express interpersonal and communication skills that result in effective information exchange and teaming with patients, patients’ families, and professional associates. - Exemplify a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. - Signify an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Qualifications - Licensure: Practice within the scope of licensure and certification consistent with Massachusetts law. - Physician Applicants: M.D. or D.O., board certification or eligibility in an appropriate specialty. - NP/PA Applicants: Graduation from an accredited program and current certification. - Supervision: Advanced Practice Clinicians (NPs/PAs) must maintain appropriate supervision/collaborative agreements. - Mandatory Regulatory Credentials: Valid and unrestricted license to practice in the Commonwealth of Massachusetts, BLS certification, and valid DEA registration and prescribing authority as applicable. - Program Eligibility: Eligible to participate in Medicare, Medicaid, and other third-party payer programs. - Team Orientation: Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting with a commitment to the PCMH model. - Cultural Competence: Ability to work effectively in a culturally diverse environment and serve a seasonal, community-based population. - Excellent written and verbal communication skills – bi-lingual helpful. - Proficiency in computer skills including EPIC, Outlook, Microsoft office, OneDrive, electronic health records and other standard office software. - Ability to adhere to strict confidentiality standards. - Demonstrated ability to work effectively both as a team member and independently.

Role Description The Remote Nurse is a key member of the Outer Cape Health Services (OCHS) clinical team, delivering high-quality, patient-centered care in a virtual environment. This position supports providers, medical assistants, behavioral health specialists, and other team members to ensure timely, coordinated, and comprehensive care for patients. The remote nurse will focus on triage, care coordination, chronic disease management, and panel management, leveraging technology and clinical protocols to maintain continuity of care and close care gaps. Summary of Duties: - Direct Patient Care & Clinical Support: - Conduct nurse visits via telehealth for chronic disease management, blood pressure checks, INR reviews, medication education, and post-hospital discharge follow-up. - Perform triage using approved clinical protocols, assess patient needs, and coordinate same-day care when necessary. - Exhibit a high level of clinical acumen and decision-making to address patients’ acute and chronic needs as part of a highly functioning team. - Reinforce treatment plans for chronic conditions (e.g., diabetes, hypertension, asthma). - Process medication refill requests per standing protocols and ensure accurate documentation. - Educate patients on proper use of medical equipment, prescribed regimens, and other self-care practices. - Provide a patient-centered experience by addressing questions, explaining procedures or testing, and connecting patients with community resources or support programs. - Prepare charts for providers in advance of patient appointments. - Quality Assurance and Improvement Projects as determined. - Patient scheduling. - Care Coordination & Panel Management: - Collaborate with providers and team members to close care gaps and ensure follow-up on labs, referrals, and preventive services. - Participate in pre-visit planning, leveraging standing orders to improve care delivery. - Review dashboards and outreach to patients to schedule recommended visits and screenings. - Assist with care transitions and follow-up after hospital or ED discharge. - Team-Based Care & Quality Improvement: - Actively participate in virtual team huddles, case conferences, and interdisciplinary care planning. - Support population health initiatives and quality improvement projects to advance OCHS’ strategic goals. - Facilitate coordination with specialty care, social services, and community-based resources to meet patient needs. - Documentation & Compliance: - Maintain accurate and timely documentation in the Electronic Medical Record (EMR) per OCHS policies. - Manage all assigned in-baskets including telephone encounters, patient messages, and overdue results. - Perform pre-visit medication reconciliation when indicated. - Communicate abnormal and normal results promptly to providers and patients. - Ensure compliance with HIPAA, infection control standards, and organizational clinical protocols. - Collaboration & Communication: - Promote teamwork by collaborating with providers, Medical Assistants, and Patient Service Representatives. - Seek guidance from the Nurse Manager for escalating concerns or complex clinical issues. - Contribute to a culture of safety by adhering to National Patient Safety Goals (e.g., patient identification, medication safety, infection prevention). - Work Environment: - Fully remote position with reliable high-speed internet required. - Occasional on-site meetings or trainings may be required. - Must maintain a HIPAA-compliant home office environment for patient confidentiality. Qualifications - Bachelor of Science, or Associate's in nursing from an accredited school of nursing by AACN. - Current Unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license from the Massachusetts State Board of Registration. - Experience working remotely in a health care role is required. - BLS Certification is Required. - Minimum of 1–2 years of clinical nursing experience preferred, ideally in a primary care or community health setting. - Experience or desire to work in team-based care model. - Maintain and enhance professional nursing skills and knowledge by attending continuing education programs. - Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting. - Excellent written and verbal communication skills – bi-lingual helpful. - Proficiency in computer skills including: Outlook, Microsoft Office, OneDrive etc. - Proficiency in Electronic Health Records (EPIC preferred). - Excellent judgment and ability to solve problems in a timely manner. - Ability to adhere to strict confidentiality standards. - Demonstrated ability to work effectively both as a team member and independently. - Demonstrated ability to work in a culturally diverse and inclusive environment. Benefits - Salary range: $32.00/hourly to $45.00/hourly. - Equal employment opportunity in all employment programs and decisions.

Role Description As a Patient-Centered Medical Home (PCMH), we are committed to providing accessible, high-quality, team-based care. Reporting to the Chief Medical Officer, the Remote Primary Care Access Clinician serves as a vital clinical extension of the interdisciplinary care team, focusing primarily on virtual access and inbox management. By efficiently managing the in-basket and conducting telehealth visits, this role ensures continuity of care, improves patient outcomes, and supports the broader OCHS team-based care model. A typical day consists of approximately 50% telehealth visits with patients and 50% in-basket management and other virtual support. Essential Functions - Serve as a member of the primary care team, providing telehealth and virtual support to an in-person primary care team. - Engage in regular and ongoing communication regarding the health of the population managed. - Utilize EPIC and a range of tools to maximize communication with patients and team members. - Collaborate with the Chief Medical Officer, Senior Medical Director, and nursing staff regarding the daily schedule. - Demonstrate flexibility and willingness to adapt based on daily patient needs. - Keep accurate, complete, legible, and timely medical and other records and files as required by law. - Participate in peer review and patient care audits for quality assurance and utilization review. - Maintain knowledge of current developments in specialty to enhance professional expertise. - Maintain a productive and professional working relationship with other clinicians and healthcare professionals. - Engage respectfully with OCHS administrative and support staff. - Perform care in accordance with all applicable state and federal laws, professional standards, and OCHS policies and procedures. - Other related duties and projects as assigned. Core Competencies / Core Clinical Competencies - Provide patient care that is compassionate, appropriate, and effective for the treatment of and promotion of health. - Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. - Investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve patient care practices. - Express interpersonal and communication skills that result in effective information exchange and teaming with patients, patients’ families, and professional associates. - Exemplify a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. - Signify an awareness of and responsiveness to the larger context and system of health care. Qualifications - Licensure: Practice within the scope of licensure and certification consistent with Massachusetts law. - Physician Applicants: M.D. or D.O., board certification or eligibility in an appropriate specialty. - NP/PA Applicants: Graduation from an accredited program and current certification. - Supervision: Advanced Practice Clinicians (NPs/PAs) must maintain appropriate supervision/collaborative agreements. - Mandatory Regulatory Credentials: Valid and unrestricted license to practice in the Commonwealth of Massachusetts, BLS certification, and valid DEA registration and prescribing authority as applicable. - Program Eligibility: Eligible to participate in Medicare, Medicaid, and other third-party payer programs. - Team Orientation: Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting with a commitment to the PCMH model. - Cultural Competence: Ability to work effectively in a culturally diverse environment and serve a seasonal, community-based population. - Excellent written and verbal communication skills – bi-lingual helpful. - Proficiency in computer skills including EPIC, Outlook, Microsoft Office, OneDrive, electronic health records and other standard office software. - Ability to adhere to strict confidentiality standards. - Demonstrated ability to work effectively both as a team member and independently.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Remote Nurse is a key member of the Outer Cape Health Services (OCHS) clinical team, delivering high-quality, patient-centered care in a virtual environment. This position supports providers, medical assistants, behavioral health specialists, and other team members to ensure timely, coordinated, and comprehensive care for patients. The remote nurse will focus on triage, care coordination, chronic disease management, and panel management, leveraging technology and clinical protocols to maintain continuity of care and close care gaps. A Day in the Life of this Role: Summary of Duties: Essential Functions - Conduct nurse visits via telehealth for chronic disease management, blood pressure checks, INR reviews, medication education, and post-hospital discharge follow-up. - Perform triage using approved clinical protocols, assess patient needs, and coordinate same-day care when necessary. - Exhibit a high level of clinical acumen and decision-making to address patients’ acute and chronic needs as part of a highly functioning team. - Reinforce treatment plans for chronic conditions (e.g., diabetes, hypertension, asthma). - Process medication refill requests per standing protocols and ensure accurate documentation. - Educate patients on proper use of medical equipment, prescribed regimens, and other self-care practices. - Provide a patient-centered experience by addressing questions, explaining procedures or testing, and connecting patients with community resources or support programs. Care Coordination & Panel Management - Collaborate with providers and team members to close care gaps and ensure follow-up on labs, referrals, and preventive services. - Participate in pre-visit planning, leveraging standing orders to improve care delivery. - Review dashboards and outreach to patients to schedule recommended visits and screenings. - Assist with care transitions and follow-up after hospital or ED discharge. Team-Based Care & Quality Improvement - Actively participate in virtual team huddles, case conferences, and interdisciplinary care planning. - Support population health initiatives and quality improvement projects to advance OCHS’ strategic goals. - Facilitate coordination with specialty care, social services, and community-based resources to meet patient needs. Documentation & Compliance - Maintain accurate and timely documentation in the Electronic Medical Record (EMR) per OCHS policies. - Manage all assigned in-baskets including telephone encounters, patient messages, and overdue results. - Perform pre-visit medication reconciliation when indicated. - Communicate abnormal and normal results promptly to providers and patients. - Ensure compliance with HIPAA, infection control standards, and organizational clinical protocols. Collaboration & Communication - Promote teamwork by collaborating with providers, Medical Assistants, and Patient Service Representatives. - Seek guidance from the Nurse Manager for escalated concerns or complex clinical issues. - Contribute to a culture of safety by adhering to National Patient Safety Goals (e.g., patient identification, medication safety, infection prevention). Work Environment - Fully remote position with reliable high-speed internet required. - Occasional on-site meetings or trainings may be required. - Must maintain a HIPAA-compliant home office environment for patient confidentiality. Qualifications - BLS/CPR certification required. - Minimum of 1–2 years of clinical nursing experience preferred, ideally in a primary care or community health setting. - Experience or desire to work in team-based care model. - Bachelor of Science or Associates in Nursing from an accredited school of nursing by AACN. - Current Registered Nurse (RN) license from the Massachusetts State Board of Registration. - Maintain and enhance professional nursing skills and knowledge by attending continuing education programs. - Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting. - Excellent written and verbal communication skills – bi-lingual helpful. - Proficiency in computer skills including EPIC, Outlook, Microsoft Office, OneDrive, etc. - Excellent judgment and ability to solve problems in a timely manner. - Ability to adhere to strict confidentiality standards. - Demonstrated ability to work effectively both as a team member and independently. - Demonstrated ability to work in a culturally diverse and inclusive environment. Company Description Outer Cape Health Services is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any protected class under federal, state, or local law is a violation of our policy and is against the law. Equal employment opportunity is provided to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, covered veterans' status, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, political affiliation, or any other protected characteristic. In accordance with Massachusetts law, we are committed to wage transparency. The salary range for this position is $35.00/hourly to $45.00/hourly. This range is provided to promote equity and transparency in our hiring process. Actual compensation may vary based on factors such as experience, qualifications, and other job-related criteria.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Remote Primary Care Clinician serves as a clinical leader within an interdisciplinary care team. Reporting to the Site Medical Director, this role provides comprehensive, continuous longitudinal care via telehealth while coordinating with an on-site partner for physical exams, urgent procedures, and localized needs. - Dyad Collaboration: Partner closely with an on-site Access Clinician to co-manage a patient panel, ensuring that remote longitudinal care and in-person clinical needs are seamlessly integrated. - Virtual Team Leadership: Lead an interdisciplinary team (RNs, MAs, Behavioral Health) using digital tools to champion shared accountability for patient outcomes. - Telehealth Panel Management: Maintain an assigned patient panel through video and telephonic visits, meeting productivity expectations while balancing quality and team-based principles. - Digital Huddles: Lead daily virtual team huddles with the Access Clinician and support staff to identify care gaps and coordinate workflow. - Clinical Oversight: Provide remote mentorship and clinical oversight to nursing and allied health staff to ensure members work at the top of their licensure. - Integrated Care: Collaborate virtually with Integrated Behavioral Health providers and Community Health Workers to address social determinants of health. - Quality & Population Health: Participate in virtual patient care audits and value-based care initiatives to improve clinical quality. - Documentation: Complete electronic documentation in a timely manner consistent with OCHS and regulatory standards. - On-Call & Coverage: Participate in remote on-call responsibilities and weekend coverage as assigned. - Other related duties and projects as assigned. Qualifications - Licensure: Must possess and maintain a valid, unrestricted license to practice in the Commonwealth of Massachusetts. - Physician Applicants: M.D. or D.O., board certification or eligibility in an appropriate specialty. - NP/PA Applicants: Graduation from an accredited program and current certification. - Certifications: BLS certification and valid DEA registration with prescribing authority. - Remote Requirements: Ability to work effectively in a private, secure home office environment. - Excellent interpersonal skills, communication skills, organizational abilities, commitment to the Patient-Centered Medical Home (PCMH) and collaborative dyad models, and the ability to work within a collaborative team setting. - Excellent written and verbal communication skills – bi-lingual helpful. - Proficiency in computer skills including EPIC, Outlook, Microsoft Office, OneDrive, etc. - Excellent judgment and ability to solve problems in a timely manner. - Ability to adhere to strict confidentiality standards. - Demonstrated ability to work effectively both as a team member and independently. - Demonstrated ability to work in a culturally diverse and inclusive environment. Company Description Outer Cape Health Services (OCHS) provides a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod. With locations in Harwich Port, Wellfleet, and Provincetown, OCHS cares for more than 20,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966). As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it and validating that staff are working at the top of their licensures are foundations of this model. Outer Cape Health Services, Inc. (OCHS) is a 501(c)(3) non-profit organization and is governed by a Board of Directors representative of its community. All board members live on Cape Cod, and the majority are OCHS patients. OCHS offers competitive benefit plans and is an inclusive and equal opportunity employer.