• Conduct comprehensive in-home health risk assessments to identify all active and chronic disease conditions, as well as determine all physical, mental, and social needs present at the time of the visit • Takes history, examines, determines diagnoses • Provides written documentation of patient visit, per NCQA standards • Takes patient vital signs, as necessary • Places case management referrals and communicates with PCP as necessary • Communicates with patients, caregivers, agency nurses, other providers and vendors as necessary to assure proper diagnosis • Performs all clinical duties while observing OSHA Universal Precautions • Maintains patient confidentiality • Attends required meetings and in-services and participates in committees, as requested • Participates in professional development activities and maintains professional licenses and affiliations

Role Description This role offers an opportunity to lead clinical care and operations for medically complex Medicaid and Dual Eligible populations in Ohio. You will provide advanced practice care virtually while guiding an interdisciplinary team to improve patient outcomes and reduce hospital visits. The position combines clinical expertise with leadership and program development in a home-centered, value-based care model. - Deliver high-quality virtual clinical care and ongoing management for medically complex Medicaid and Dual Eligible members - Lead, mentor, and develop the Ohio interdisciplinary clinical team fostering collaboration, accountability, and a culture of excellence - Build and scale local clinical operations establishing workflows, best practices, and performance standards - Provide coaching, oversight, and performance management for team members supporting professional development - Conduct patient assessments, medication management, care planning, and follow-up through telehealth and remote care technologies - Coordinate care with primary care providers, specialists, managed care organizations, and community partners - Lead and document advance care planning and goals-of-care conversations with patients and families - Ensure accurate and compliant clinical documentation supporting HCC coding, risk adjustment, and quality initiatives including STAR and HEDIS gap closure - Assist with hospital admission and discharge planning ensuring smooth transitions back to the home setting - Contribute to development and continuous improvement of clinical protocols, operational processes, and value-based care strategies Qualifications - Master's degree or higher - 1+ years of experience in ANY of the following: - Allscripts Care Management - Telemedicine Care - Care Management - ANY of the following valid licenses/certifications: - Nurse Practitioner (NP) - Family Nurse Practitioner (FNP) - Psychiatric-Mental Health Nurse Practitioner (PMHNP) - ANY of the following valid licenses/certifications: - Adult Gerontology Nurse Practitioner (AGNP) - Gerontological Nurse Practitioner (GNP)

• Conduct initial and follow-up telehealth evaluations • Provide care for both substance use and mental health conditions • Prescribe medications as appropriate and respond to member questions • Complete timely documentation in our EHR (Healthie) • Collaborate with your care team and participate in scheduled team meetings

• Assesses patient needs within a telemedicine care setting • Appropriately triages patients to differentiate the patient needs • Evaluates patients in a timely manner, putting patient care above clerical duties • Performs a thorough history and physical exam on each patient • Creates an individualized, evidence-based plan of care • Appropriately consults the on-call WellNow physician and on-call radiologist • Effectively manages payers across the spectrum of services provided at a site • Follows evidence-based standards for ordering laboratory, radiology and other diagnostic studies • Uses evidence-based resources for treatment options • Orders and prescribes appropriate medications • Appropriately consults and refers to primary care and specialty physicians • Performs procedures appropriate type of services provided at the standard of care • Educates patients regarding the disease process and discharge plan • Maintains patient confidentiality