Duties and Responsibilities:

Direct Clinical Care & Billable Services:

• Perform comprehensive, billable patient visits in virtual, clinic, or community-based settings, including:
  • Annual Wellness Visits (AWVs)
• Chronic Care Management (CCM)
• Transitional Care Management (TCM)
• Primary care and follow-up visits
• Conduct complete medical histories, physical exams, and risk assessments.
• Diagnose and manage acute and chronic conditions within scope of practice.
• Order, interpret, and follow up on diagnostic tests and labs.
• Prescribe medications and treatments in accordance with state law, protocols, and collaborative agreements.
• Refer patients to specialists or supervising physicians when clinical needs exceed scope.
• Provide health education, preventive counseling, and self-management support to patients and caregivers.

Population Health & Value-Based Care Activities:

• Identify, document, and accurately code chronic conditions (HCC/RAF) to support risk adjustment and appropriate reimbursement.
• Close gaps in care related to preventive screenings, immunizations, and chronic disease management.
• Develop and implement individualized, longitudinal care plans in collaboration with patients and care teams.
• Utilize population health data, registries, and dashboards to prioritize high-risk patients.
• Support achievement of quality benchmarks, including HEDIS, STAR measures, UDS-related measures, and payer-driven metrics.
• Contribute to reducing hospital admissions, readmissions, and emergency department utilization.

Care Coordination & Interdisciplinary Collaboration:

• Collaborate closely with physicians, clinical pharmacists, nurses, case managers, social workers, and community partners.
• Participate in interdisciplinary team meetings, case conferences, and care planning discussions.
• Communicate effectively with health plans, payers, hospitals, and post-acute providers to ensure continuity of care.
• Support transitions of care and timely post-discharge follow-up.

Clinical Leadership, Oversight & Quality Improvement:

• Provide direct supervision, clinical guidance, mentorship, and support to APPs, licensed, and unlicensed population health staff as assigned.
• Assist with onboarding and training related to workflows, documentation standards, and value-based care principles.
• Participate in performance improvement (PI) and quality improvement initiatives.
• Contribute clinical insight to workflow optimization and care delivery model development.
• Participate in payer meetings or internal reviews related to quality, utilization, and performance outcomes.

Documentation, Compliance & Professional Practice:

• Ensure timely, accurate, and compliant documentation in the EHR to support billing, quality reporting, and regulatory requirements.
• Maintain licensure, certification, prescriptive authority, CPR certification, and credentialing requirements.
• Adhere to organizational policies, HRSA/FQHC standards, and scope-of-practice regulations.
• Demonstrate flexibility and adaptability to meet changing organizational and patient needs.
• Perform other duties as assigned by Population Health or Clinical Leadership.

Qualifications:

Education & Licensure /Experience:

• Licensed Nurse Practitioner (FNP, AGNP) or Physician Assistant in the State of South Carolina.
• National board certification (FNP-C, AGNP-C, PA-C).
• Master's degree in Nursing or Physician Assistant Studies required.
• Current prescriptive authority and DEA registration.
• Current CPR certification.
• Experience in primary care, family medicine, internal medicine, geriatrics, or population health preferred.
• Experience with AWVs, CCM, TCM, and value-based care visits strongly preferred.
• Knowledge of HCC/RAF coding and quality metrics preferred.
• Prior leadership, mentoring, or supervisory experience preferred.
• Experience working in FQHCs or managed care environments a plus.