Provide brief telehealth intake visits for older adults to establish medical necessity for care navigation services and identify high-risk conditions and unmet social needs. This role also includes reviewing documentation, supporting individualized care plans, and coordinating with care advocates and nurse care managers to align clinical and social needs. The work is remote and supports a tech-enabled, integrated care model focused on safe enrollment into ongoing support.
Key Responsibilities
- Conduct telehealth E/M visits or Annual Wellness Visits to determine eligibility for care navigation services.
- Identify high-risk conditions, unmet social needs, diagnoses, and risk factors during intake.
- Document findings in the platform using accurate coding, diagnoses, risk factors, and SDOH Z-codes.
- Validate and approve individualized care plans in alignment with the patient’s medical treatment plan.
- Collaborate with care advocates and nurse care managers to finalize support plans.
- Support compliant and compassionate enrollment into the appropriate level of care navigation.
Required
- Completion of an accredited Nurse Practitioner program.
- Active Nurse Practitioner or APRN license in good standing.
- Multi-state licensure.
- At least 2 years of experience in primary care, telehealth, or care management.
- Familiarity with Medicare programs, care navigation, incident-to requirements, and SDOH documentation.
- Proficiency with EMRs, care management platforms, and telehealth workflows.
Preferred
- Bilingual ability.
Benefits & Perks
- Remote work.
- Flexible contractor (1099) arrangement.
- Opportunity to help shape an integrated, tech-enabled care advocacy model.
- Collaborative work with care advocates and clinical operations teams.