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Medical Home Network

Integrates safety-net providers for value-based care

Geriatric Advanced Practice Provider

Full-TimeUpdated on 10/21/2026
No salary listed
Mid
Master's, PhD
Pauls Valley, OK, USA+3 moreMore locations: Lindsay, OK, USA | Oklahoma City, OK, USA | Chickasha, OK, USA
In PersonOnsite at partner health center locations across Central Oklahoma.
Medical, Clinical & VeterinaryAdvanced Practice Providers

About the job

Requirements
  • An active Nurse Practitioner license in Oklahoma is required.
  • National Nurse Practitioner certification from AANP or ANCC, or Physician Assistant certification, is required.
  • Experience in geriatric care is required.
  • Demonstrated experience conducting Annual Wellness Visits and Advance Care Planning discussions is required.
  • Prior experience building or scaling clinical programs is required.
  • Experience with primary care or population health is required.
  • A background in value-based care, risk adjustment, or quality initiatives is required.
  • Familiarity with electronic health record documentation and Medicare compliance is required.
  • Experience working with interdisciplinary or care management teams is required.
  • A Master’s degree or higher from an accredited Nurse Practitioner or Physician Assistant program is required.
  • A current, unrestricted Nurse Practitioner or Physician Assistant license in Oklahoma is required.
Responsibilities
  • Provide comprehensive primary and preventive care services to aging patients enrolled in contracted health centers.
  • Perform thorough assessments focused on chronic disease management, functional status, cognitive health, fall risk, and medication management.
  • Develop individualized, patient-centered care plans with patients, caregivers, and interdisciplinary teams.
  • Conduct Medicare Annual Wellness Visits, including health risk assessments, cognitive and depression screenings, fall risk and functional assessments, medication reconciliation, and preventive care planning and referrals.
  • Ensure accurate documentation and compliance with regulatory and payer requirements.
  • Identify gaps in care and initiate appropriate follow-up or care coordination.
  • Lead patient-centered Advance Care Planning discussions with patients and families.
  • Assess patient goals, values, and preferences for future medical care.
  • Facilitate completion and documentation of advance directives, POLST/MOLST forms, and related Advance Care Planning documentation as appropriate.
  • Collaborate with care teams to ensure Advance Care Planning preferences are understood and honored across care settings.
  • Contribute to the design, implementation, and scaling of clinical programs focused on geriatric care, preventive services, and population health.
  • Help define workflows, clinical protocols, and quality standards for Annual Wellness Visits, Advance Care Planning, and related initiatives.
  • Partner with operations, clinical leadership, and quality teams to improve efficiency, outcomes, and patient experience.
  • Work closely with physicians, nurses, care managers, social workers, and other interdisciplinary team members.
  • Support quality improvement initiatives, documentation accuracy, and performance metrics related to value-based care.
  • Educate patients, caregivers, and staff on preventive care, aging-related health topics, and care planning.
  • Directly manage Medical Assistant(s).
Desired Qualifications
  • Experience working in Federally Qualified Health Centers or similar community health settings is strongly preferred.
  • Fluency in Spanish is preferred.

About the company

Medical Home Network (MHN) is a public-benefit organization that strengthens care for underserved communities by uniting safety-net providers around value-based care. It partners with Federally Qualified Health Centers and other safety-net groups to help them succeed under payment models that reward outcomes rather than volume. MHN uses the MHNConnect platform, a secure web-based system that links clinics, hospitals, and care teams to share near real-time patient data, coordinate care, and manage high-risk patients, especially during hospital transitions, while incorporating social determinants of health. The goal is to reduce avoidable ER visits and readmissions, expand its technology and provider partnerships, and improve population health and health equity.

Company Size

51-200

Company Stage

N/A

Total Funding

N/A

Headquarters

Chicago, Illinois

Founded

2009

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Benefits

  • Paid Vacation
  • Paid Sick Leave
  • Paid Holidays
  • Tuition Reimbursement
  • Health Insurance
  • Vision Insurance
  • Dental Insurance
  • Health Savings Account/Flexible Spending Account
  • Commuter Benefits
  • Hybrid Work Options

Company News

Yahoo Finance
Oct 13th, 2026
Diverge Health merges with Medical Home Network to serve 500,000 members and $3B in medical spend

Diverge Health is merging with Medical Home Network (MHN), a public benefit corporation that works with federally qualified health centers (FQHCs). The deal, announced October 13, 2026 in Chicago, creates one of the largest US value-based care organisations focused on under-resourced communities. In 2027, the combined company will partner with nearly 100 FQHCs, more than 300 independent practices, and over 20 payor partners across nine states. It will support nearly 500,000 members and $3 billion in medical spend. Binoy Bhansali will be chief executive officer of Diverge Health. MHN chief executive Cheryl Lulias will become co-founder and president of MHN, which will operate under the Diverge platform. Oak HC/FT will join the Diverge board, alongside Triple Aim Partners and GV.

GlobeNewswire
Oct 13th, 2026
Diverge Health merges with Medical Home Network to strengthen value-based care for safety-net providers and patients.

Diverge Health merges with Medical Home Network to strengthen value-based care for safety-net providers and patients. The combined company is creating a new standard to drive better outcomes for providers dedicated to under-resourced communities. October 13, 2026 08:00 ET | Source: Diverge Health CHICAGO, Oct. 13, 2026 (GLOBE NEWSWIRE) - Diverge Health, an organization that partners with primary care practices to strengthen the care they deliver to underserved patients, today announced they are merging with Medical Home Network (MHN), a public benefit corporation (PBC) that partners with federally qualified health centers (FQHCs) to build healthier communities. The combined company will create one of the largest value-based care organizations in the country dedicated to under-resourced communities. The merger brings together two mission-aligned organizations with a shared founding history in Medicaid, proving their models on the hardest-to-reach and most socially complex populations before expanding into Medicare. MHN has spent more than 15 years working alongside community health centers and launched one of the first and most successful FQHC focused Medicaid ACOs nationally. Diverge has largely built its network across independent primary care practices and invested heavily in community-based care teams, delivering a 2% reduction in population-level medical loss ratio with a national payer and a 6% increase in patients visiting their primary care provider in 2025. Together in 2027, the companies will partner with nearly 100 FQHCs, more than 300 independent practices, and over 20 Medicaid and Medicare payor partners across nine states, supporting nearly 500,000 members and $3 billion in medical spend. The combined organization will embed local community health teams alongside partner practices so that providers can proactively address patients' clinical, behavioral, and social needs and reduce total cost of care. The company's proprietary risk modeling identifies rising-risk patients early and puts those insights and auto-generated care plans in the hands of local teams. Through continued investments in AI, the company aims to lower the cost of engaging each patient while extending providers' reach and preserving the relationships patients already trust. "Value-based care is notoriously hard, especially in Medicaid, but strengthening our country's primary care backbone and supporting their patients to live their healthiest lives is a moral imperative," said Binoy Bhansali, CEO and Co-Founder of Diverge Health. "Together, we are proving that succeeding in value-based care is very much possible if you support these practices with the right infrastructure, community health teams, and data." The merger comes at a pivotal moment for the industry, with the Centers for Medicare & Medicaid Services putting its weight behind value-based payment models increasingly meant to support community health centers and independent providers, and a growing number of state Medicaid procurements requiring health plans to do the same. Safety net providers benefit from strategic partners like Diverge and MHN to participate in these models. "FQHCs care for the patients in this country who need it most. They deserve partners who share their mission and understand the complexity of their work," said Cheryl Lulias, President and CEO of MHN PBC. "This merger brings more capacity, infrastructure, and community-based resources to our partnerships with FQHCs, helping extend the model beyond the practice." Art Jones, Chief Clinical Officer of MHN PBC and Principal at HMA, said, "One in seven Americans receives care at an FQHC. Those health centers care for patients with some of the most complex medical and social needs in the country, and they're being asked to do it on reimbursement that hasn't kept pace. Value-based care is one of the few ways to close that gap. This combination puts more resources behind the work health centers are already doing, rather than asking them to do something different." Binoy Bhansali will be CEO of Diverge Health and Cheryl Lulias will serve as Co-Founder and President of MHN PBC, leading a combined leadership team drawn from both organizations. MHN PBC will continue to operate under the Diverge platform. Oak HC/FT will join the Diverge Health Board, alongside Triple Aim Partners and GV. About Diverge Health Diverge Health brings local population health support including community health teams, administrative support, and technology to primary care providers focused on serving underserved populations. They partner with payors to structure risk arrangements on these providers' panels, aligning all parties to improve quality and manage cost. About Medical Home Network Medical Home Network (MHN) is a public benefit corporation with a mission to transform care in the safety net and build healthier communities. MHN partners with federally qualified health centers throughout the country to help them build the capabilities to be successful value-based care providers. MHN's model of care and approach consistently delivers leading health outcomes, savings, and quality results in value-based care arrangements. Media Contact Kayli Watson [email protected] +19197499126