About the role
This is a remote position.
Cares for and manages medically complex Medicaid and Dual-Eligible populations in Ohio, providing advanced practice care virtually while guiding an interdisciplinary team to improve patient outcomes and reduce hospital visits. Combines clinical expertise with leadership and program development in a home-centered, value-based care model.
Duties
Deliver high-quality virtual clinical care and ongoing management for medically complex Medicaid and Dual Eligible members
Conduct patient assessments, medication management, care planning, and follow-up via 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, compliant clinical documentation supporting HCC coding, risk adjustment, and quality initiatives (STAR/HEDIS gap closure)
Assist with hospital admission and discharge planning, ensuring smooth transitions back to the home setting
Contribute to the development and continuous improvement of clinical protocols, operational processes, and value-based care strategies
Participation in a rotating 24/7 triage and after-hours support model
Requirements
Ideal Background
Comfortable practicing autonomously with full prescriptive authority
Significant experience with telehealth, virtual care, or remote patient management
Experience working with medically complex adults, elderly populations, individuals with disabilities, or home-based care models
Working knowledge of value-based care, HCC coding, risk adjustment, quality gap closure, STAR ratings, and HEDIS measures
Experience conducting advance care planning and goals-of-care discussions with patients and families
Entrepreneurial mindset, comfortable in a dynamic, startup-like environmentJoin us to be part of a forward-thinking healthcare organization
Qualifications Required:
Must live in Ohio
Education
Master's degree or higher
Experience
Primary Care (3+ years)
Licenses/Certifications
ANY of the following valid licenses/certifications:
Family Nurse Practitioner (FNP) in Ohio (OH)
Adult Gerontology Nurse Practitioner (AGNP) in Ohio (OH)
Minimum of 3–5 years of advanced practice clinical experience
Benefits
Health Insurance
Originally posted on Himalayas