Medical Home Network · 22 hours ago
Geriatric Advanced Practice Provider
Oklahoma
Full-time
Hybrid
Mid, Senior LevelMedical Home Network is a mission-driven public benefit corporation focused on transforming care in the safety net and reducing health disparities. The Geriatric Advanced Practice Provider will deliver high-quality, patient-centered care to an aging population while contributing to program design and continuous improvement.
Health CareHospitalMedicalNon Profit
Responsibilities
Provide comprehensive primary and preventive care services to aging patients enrolled in MHN’s contracted health centers
Perform thorough assessments with a focus on chronic disease management, functional status, cognitive health, fall risk, and medication management
Develop individualized, patient-centered care plans in collaboration 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, 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 compassionate, 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 ACP documentation as appropriate
Collaborate with care teams to ensure ACP preferences are understood and honored across 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 AWVs, ACP, 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 managing Medical Assistant(s)
Qualification
Required
Active Nurse Practitioner license (OK)
National NP certification (AANP or ANCC) or PA certification
Experience in geriatric care required
Demonstrated experience conducting AWVs and ACP discussions
Strong communication skills and comfort with sensitive conversations
Experience working in FQHCs or similar community health settings is strongly preferred
Prior experience building or scaling clinical programs
Experience with primary care or population health
Background in value-based care, risk adjustment, or quality initiatives
Familiarity with EHR documentation and Medicare compliance
Experience working with interdisciplinary or care management teams
Master's degree or higher from an accredited Nurse Practitioner or Physician Assistant program
Current, unrestricted Nurse Practitioner (NP) or Physician Assistant (PA) license in the state of OK
Benefits
Medical
Vision
Dental
HSA
FSA
401k
Fitness reimbursement
Commuter benefits
Tuition assistance
Paid time off
Sick time
12 paid holidays
Company
Medical Home Network
Medical Home Network is transforming health care delivery for Medicaid patients by fostering collaboration and innovation.
Founded in 2009
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Cheryl Lulias
President & Chief Executive Officer (CEO) ‧ Medical Home Network
Ashley Snyder
Chief Development Officer
Recent News
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