• Conduct Comprehensive Health Assessments through telehealth • Document HCC risk adjustment during patient visits • Close HEDIS (quality measures) care gaps • Review medical history, medications, and preventive needs • Document visits using ICD-10 and CPT II codes • Deliver clear care plans and follow-up guidance • Maintain accurate documentation for quality programs

• Conduct Comprehensive Health Assessments through telehealth • Document HCC risk adjustment during patient visits • Close HEDIS (quality measures) care gaps • Review medical history, medications, and preventive needs • Document visits using ICD-10 and CPT II codes • Deliver clear care plans and follow-up guidance • Maintain accurate documentation for quality programs

• 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)