Our focus is comprehensive care at home to improve outcomes and reduce total healthcare costs. We are a group of clinical professionals that understand the needs of patients, medical professionals, health systems and payers. A main focus of our practice is:

　　Comprehensive Health Risk Assessments (HRA): Our team conducts in-home comprehensive health assessments in order to ensure patient’s medical well being and to provide accurate data for HCC (Hierarchical Condition Categories) coding, STAR ratings and reimbursement.

　　Complex Care Program (CCP): health plans look to us to conduct in-home longitudinal care for medically complex patients with chronic illnesses in an effort improve clinical outcomes. Our team collaborates with the patients’ primary care physicians (PCPs), and our visits serve as an adjunct to the care delivered by the PCP.

　　Chronic Care Management (CCM): Our team contracts with and receives referrals from health plans to assume primary care of chronically ill patients with high admission rates and multiple emergency department visits in an effort to improve clinical outcomes. Nurse practitioners work alongside physicians delivering care in the patient’s home.

　　Duties & Responsibilities:

　　Performing home visits with patients enrolled in our Complex Care Program. Initial visits are comprehensive evaluations with subsequent visits targeting risk factors for disease exacerbations and hospitalizations;

　　Function as day-to-day clinical leader, providing decision support to nurse practitioners and collaborating with the multidisciplinary team

　　Perform preventive visits daily to optimize chronic conditions, assess home environment, and develop proactive care plans

　　Educating patients and/or patient’s family on chronic medical conditions, preventative care, and medication adherence compliance;

　　Perform urgent care visits in the home and telephonically to avoid unnecessary ED transfers and hospital admissions

　　Leverage the support of care team such as: nurse care manager, behavioral health, social work, and pharmacy to meet patients’ medical, biopsychosocial, and financial needs

　　Assume responsibility as home-based PCP in some cases where there is no PCP and in other cases co-manage the patient with the PCP and serve as an extension of clinical care into the home

　　Coordinate with other physicians across the continuum of care, including hospitalist, specialists, PCP’s (in some cases), and SNF providers to smooth transitions and prevent readmissions

　　Perform Telehealth visits at times when needed

　　Complete appropriate and thorough clinical documentation of acute and chronic health issues through patient encounter in EMR system;

　　Complete EMR documentation in a timely manner; Ensuring all appropriate consent forms are signed and dated; Interpreting laboratory data and diagnostic testing when available to assist in diagnosis of medical conditions;

　　Performing ADL and fall risk assessments; cognitive impairment, depression, and nutritional health screening; BMI measurement; medication reconciliation;

　　Participating in frequent telephonic clinical meetings and web-based trainings; however, provider will occasionally be required to attend on-site training for which the provider will be reimbursed;

　　Complete chart reviews for advanced practice providers as determined by market Participating in quality processes such as medical documentation audits and quality projects;

　　Serving as a mentor or coach to advance practice providers in ongoing quality and performance improvement processes;

　　Improving provider relations through direct communication, knowledge of appropriate evidence-based clinical information, and the fostering of positive collegial relationships;

　　Performing other duties as assigned by the practice manager or medical director.

　　Perform HRA (health risk assessments) on patient panel

　　Interpreting laboratory data and diagnostic testing when available to assist in diagnosis of medical conditions;

　　Sharing after hour on-call coverage with other providers on the team;

　　Having the ability and the experience to prescribe medications, order labs or diagnostic testing, and recommend sub-subspecialty referrals.

　　Qualifications:

　　Board Certification in Internal Medicine or Family Medicine;

　　Geriatric Medicine subspecialty training or experience preferred;

　　DEA license and State Controlled Substance license upon hire;

　　Experience with electronic medical records is required.

　　Must have valid state driver’s license, be able to drive your car, provide your own vehicle, and have proof of adequate automobile insurance;

　　Highly motivated, self-directed professional with strong organizational skills and comfortable working independently on a daily basis;

　　Effective leadership and interpersonal skills; facilitates problem resolution and maintains a professional demeanor in difficult situations;

　　Excellent verbal and written communication skills;

　　Proven ability to perform comprehensive, adult and geriatric physical exams;

　　Demonstrated ability to recognize conditions, characteristics, and behaviors that place seniors at risk

　　Proven ability to pursue feedback, continuing education and professional development;

　　Candidate must be willing to travel up to a 30-60 mile radius from their home zip code ;

　　Proof of yearly influenza vaccination, Hepatitis B vaccination, and TB testing required.

　　Certifications:

　　Must have current BLS certification

　　Must have active/unrestricted license in state of position opening

　　Must be able to be credentialed by Medicare, Medicaid, and other Private Insurance Companies

　　If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

　　About Cigna Healthcare

　　Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

　　Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

　　If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.

　　The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.