Nurse Practitioner

Salary Range: 115000 to 155000 (Currency: USD) (Pay period: per-year-salary)

Responsibilities will include:

• Patient Care Delivery
• Conduct virtual onboarding and follow-up visits, facilitated by a Health Advocate, to complete comprehensive biopsychosocial assessments, diagnose and manage chronic conditions using evidence-based guidelines, perform preventive screenings, and close preventive and quality care gaps
• This includes addressing BOTH medical and behavioral health diagnoses and treatment plans including chronic disease management, acute medical issues, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance use disorders, and other mental health disorders 
• Guarantees every patient is seen face-to-face annually and proactively completes additional visits when clinical needs or care gaps arise
• Order and follow up on labs and imaging to inform diagnosis, prevention, and treatment
• Manage patients with chronic conditions (e.g., hypertension, diabetes, COPD, heart disease) in collaboration with external providers by developing individualized, evidence-based care plans to optimize health outcomes
• Manage patients with substance use disorders and prescribe medications for opioid use disorders, such as suboxone, and medications for alcohol use disorder, such as naltrexone (IM/PO) or acamprosate (this includes suboxone induction and outpatient alcohol detox for patients who are candidates, in supervision with the our Psychiatrist)
• Prescribe long-acting injectable medications for appropriate patients
• Provide health coaching, lifestyle counseling, and patient education to promote self-management and improved outcomes
• Coordinate necessary referrals or home-based services with specialists and community partners
• Participate in a rotating call schedule to address urgent clinical needs and support more healthy days at home
• Clinical coverage and training in the Collaborative Care and Bridge Programs, including Behavioral Health Case Conference, for coverage when colleagues are on leave or vacation 
• Interdisciplinary Collaboration
• Work in close collaboration with Health Advocates- providing clinical support and guidance to their activities to help them coach and empower patients on successful self-management of their health, particularly with outpatient SUD treatment, LAI management, and mental health accompaniment
• Work in close collaboration with our Behavioral Health Clinicians in supporting clinical goals and co-managing patients
• Refer, collaborate and co-manage patients with our nursing and pharmacy teams
• Collaborate with external providers and community organizations to ensure care aligns with patient goals as well as social, home health, and DME needs (this particularly includes external psychiatrists and care managers in community mental health) 
• Participate in the Advanced BH Case Conference where you will refine treatment plans in a multi-disciplinary fashion, addressing clinical documentation, quality gaps, treatment planning, transitions of care, and complex care planning
• Clinical Diagnosis and Documentation, Quality, and Compliance
• Ensure accurate and appropriate diagnosis, coding and documentation of chronic conditions with evidence-based treatment plans, including BOTH physical and mental health conditions
• Maintain timely, accurate documentation in EMR and custom care platforms
• Own the quality of preventative care delivered by helping patients close HEDIS quality gaps
• Respond to clinical documentation queries in a timely manner
• Technical Fluency and Innovation
• Quickly learns and adapts to new tools, software, and systems—including AI-driven solutions—that support patient engagement, care coordination, and clinical decision-making
• Understands the intersection of healthcare and technology, leveraging data-driven platforms, electronic medical records, and AI-enabled insights to independently problem solve and improve patient outcomes and operational efficiency
• Performs other duties as assigned

What makes you a fit for the team:

• Passionate about patient-centered, holistic healthcare
• Desire to work primarily with patients with severe mental illness and substance use disorders to improve both their medical and behavioral health care through true integration
• Thrives in a fast-paced environment and able to adapt and contribute to continuous improvement
• Exhibits calm, confident clinical decision-making even in ambiguous or rapidly changing situations
• Demonstrates a strong clinical ‘detective’ mindset, investigating across multiple systems to uncover the right diagnosis and supporting evidence, consistently seeking the ‘how’ and ‘why’ while thoroughly documenting patients’ conditions and needs
• Comfortably manages high volumes of work, and adapts quickly as priorities shift
• Fluent in technology and excited to incorporate new technology and systems into daily practice
• Adaptable and flexible, embracing evolving systems and technology-driven workflow enhancements
• Demonstrates strong growth mindset, including the willingness to unlearn prior workflows and embrace new approaches
• Works collaboratively with teammates and actively seeks opportunities to learn, grow, and elevate team performance, which includes trusting the clinical skills of team members such as behavioral health clinicians 
• Displays trust in the organization’s mission, values, and direction, and contributes positively to a culture of shared purpose
• Flexible and adaptive—comfortable working in a fast-paced, evolving startup culture
• Excited about leveraging technology to improve outcomes and access
• A strong communicator and collaborator who values teamwork and innovation

Desired skills and experience:

• Required
• Active Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of employment and willingness to obtain additional licensure as requested
• Active DEA registration or eligibility to obtain; X-waiver preferred but not required
• Active or eligible state-controlled substance license
• Current Basic Life Support (BLS) certification
• Demonstrated strong clinical judgment and ability to make independent medical decisions
• Proficiency in using electronic medical record (EMR) systems
• 5+ years of experience working in high risk populations with serious mental illness and substance use disorder with co-occuring complex medical conditions
• 2+ years of experience in assessing, provisional diagnosis, planning, and managing behavioral patient care as acquired through clinical experience
• Expertise with DSM5 diagnostic criteria
• Highly skilled in trauma-informed care and culturally sensitive care.
• Experience and comfort working within an interdisciplinary care team, and specifically closely collaborating with community health workers and primary care providers
• Preferred:
• Certification by the American Nurses Credentialing Center (ANCC) in Psychiatric Mental Health (PMH) as a Psychiatric Mental Health Nurse Practitioner (PMHNP) or Physician Assistant with Psychiatry CAQ
• Experience in working in community mental health and/or integrated care settings
• Experience working with patients with substance use disorders including prescribing suboxone, naltrexone, acamprosate, and benzodiazepines for detoxification 
• Experience working in value-based care setting and/or managed care, including how to appropriately assess STARS/HEDIS measures, accurately and appropriately diagnose and code clinical comorbidities, and identify clinical care gaps