Job Summary:

The Comprehensive ACP, reporting to the Market Medical Director, will be an integral part of the clinical team. The Comprehensive ACP is responsible for seeing our highest priority members either in-center or through the Doxy.me telehealth platform and closing all remaining care gaps for the calendar year in a single visit.

Essential Duties/Responsibilities:

• Conduct Prospective Chart Prep for clinical diagnostic and quality opportunities of identified members sufficiently in advance of member visits to ensure there is a plan to comprehensively address open care gaps for every member encounter.
• Engage with center leadership and care team members to ensure members are prioritized for scheduling based on outstanding care gaps and maintain a target schedule template fill rate of 75%.
• Complete encounters with identified members in-center or using ArchWell Health’s approved telehealth platform(s).
• Address all historical and suspected conditions presented via point of care interface (VIM).
• Address all open HEDIS measures of Focus On Care (FOC), including performing point of care testing that can be closed in an ArchWell Health center.
• Interpret evidence-based practice screenings including point of care testing.
• Formulate a list of current medical conditions using clinical knowledge and judgment.
• Document an assessment and plan for all chronic conditions in the EMR to align with the PCP treatment plans.
• Refill routine medication in appropriate quantities per ArchWell Health’s Standing Order (see attached). Controlled substances are excluded from this Standing Order and should be referred to PCP.
• Coordinate appropriate follow up care and maintain effective communication with the member’s assigned care team to facilitate effective continuity of care
• Identify urgent and emergent situations and intervene appropriately.
• Educate members on topics such as disease process, preventative screening schedule, and medication adherence.
• Maintain a high level of engagement and attend all training sessions and center meetings; demonstrate strong proficiencies with Clinical Documentation Improvement (“CDI”) education; and assist other providers to understand CDI concepts.
• Complete and lock Encounter Notes timely as per ArchWell Health’s standards.
• Perform at above-average member experience metrics.

Required Education and Experience:

• Active NP or PA license or ability to obtain by start date. Licensure must be unencumbered, free of any open/unresolved disciplinary actions including probation or restrictions against privilege to practice.
• Active ANCC, AANP, or PA national certification in Family, Geriatrics, Adult, Adult-Gerontology Primary Care, or Adult-Gerontology Acute Care certification
• Ability to complete physical requirements of the job including lifting a 30-pound bag in and out of the car, navigating stairs and a variety of dwelling conditions, and sit, stand, and kneel to perform physical assessment.
• 1+ years of clinical experience in their highest level of education, clinical setting
• Experience in gerontology, cardiology, internal medicine, or endocrinology
• Ability to travel within license state if requested for additional incentives (with notice, based on business needs)

Knowledge, Skills, and Abilities:

• Experience with Electronic Medical Records
• Advanced knowledge of ICD-10 diagnosis codes.
• Advanced knowledge of diagnostic criteria.
• Medicare Advantage experience including knowledge of the HCC model and STARs
• Ability to create, plan, implement and evaluate patient specific care plans
• Ability to exercise use of independent judgement
• Sensitivity to the diverse needs of culturally diverse staff, patients, and communities
• Embodies and serves as a role model of ArchWell Health’s Values:
  • Be compassionate
  • Strive for excellence
  • Earn trust
  • Show respect
  • Stay resilient
  • Always do the right thing

ArchWell Health is a new, innovative healthcare provider devoted to improving the lives of Adults 60+. We deliver best-in-class care at comfortable, accessible neighborhood clinics where seniors can feel at home and become part of a vibrant, wellness-focused community. Our members experience greater continuity of care, as well as the comfort of knowing they will be treated with respect by people who genuinely care about them, their families, and their communities.