Director Value Based Care Jobs in Puerto Rico (NOW HIRING)

Position: Advanced Practice Provider (NP/PA) Bilingual English/Spanish

Location: Ponce, PR, Puerto Rico

Job Id: 321

# of Openings: 1

Duo Health is a new type of medical group designed around the needs of patients with chronic kidney disease and their physicians. Our unique Health Mobilization™ platform partners multidisciplinary care teams with community nephrologists and activates all the other clinicians, facilities and community organizations necessary to treat the whole patient on their own terms. Our team is comprised of leaders in value-based health care, technology and behavioral science who share a vision for advancing health equity one relationship at a time.

Our interprofessional care teams, which include physicians, nurses, social workers, and patient navigators, provide high-touch and comprehensive care to a small panel of patients. Team collaboration is essential to our intensive, psycho-social model of care which includes assessment, medication management, social management, and behavioral health management. Duo Health is dedicated to ensuring our staff reflects the diversity of our patient population and applicants whose work demonstrates a commitment to issues of diversity are encouraged to apply.

The Advanced Practice Provider will act as part of a care team that directly interfaces with a panel of patients with CKD stages 3b, 4, 5, and ESRD in order to drive quality value-based care. He/she will interact with and evaluate patients in the home, at other sites in the community, via teleconference, or via telephone as appropriate. In this role, the NP will create close working relationships with the care team members to enhance the impact of each care team member in working with their patient panel.

Location: This role provides in-home care across the Ponce area. Nurse Practitioners operate as part of a care team and travel to patient residences or to other locations to meet patients. This is not an office-based or clinic-based position.

Work hours: Monday–Friday, 8:00 am–5:00 pm with paid after hours on call rotation

• Assume responsibility for an assigned panel of patients in collaboration with the Duo Healthcare team; provide clinical care and supports focused on patient-level interventions
• Complete history and physical exams, order laboratory and diagnostic tests as needed, and evaluate test results.
• Educate patients about medication usage and side effects, and prescribe medications as permitted by regulatory authorities.
• Identify and manage patients’ clinical conditions and psychosocial care.
• Participate in regular care team huddles.
• Perform structured assessments and develop and implement comprehensive care plans for the patient panel.
• Educate patients and caregivers about clinical conditions and treatment plans.
• Determine the need for consultation from medical, surgical, and/or behavioral health specialties.
• Facilitate care across care settings, including emergency department, hospital, skilled nursing facility, home health agency, hospice, and/or community-based organizations as appropriate.
• Be available for after-hours telephonic support as needed.
• Document all encounters accurately and in a timely manner.
• Assist in the development, implementation, and improvement of clinical protocols and guidelines of care to optimize patient engagement and experience, patient quality of life, chronic condition documentation, quality of care as determined by HEDIS and Duo Health measures, clinical outcomes that reduce unnecessary medical spend.
• Maintain confidentiality in regards to all patient sensitive information.
• Communicate effectively with other members of the Duo Health care team as well as partner clinicians related to patient needs, tests, and care.
• Support other care team members to enhance care team member experience.
• Support and participate in company efforts for continuous quality improvement.
• Adhere to all company policies and procedures.

• Licensed Advanced Practice Nurse (APN), eligible to practice in Puerto Rico.
• Bilingual English / Spanish; ability to communicate effectively both orally and in writing.
• Must meet Duo Health clinician credentialing criteria, including passing a background check.
• Consistent access to a car, an active Driver's License and a verifiable good driving record with insurance. Must be able to travel to patient homes.
• Must be self-motivated and able to perform work in accordance with defined operating procedures.
• Ability to develop and maintain inclusive and equitable relationships with patients, caregivers and staff.
• Experience with significantly complex patients in hospital environments preferred.
• Experience with chronic kidney disease or end stage kidney disease on dialysis preferred.
• Experience working with community resources from diverse backgrounds.
• Must be comfortable interacting with patients and care teams both telephonically and in-person.