JOB DESCRIPTION- Perform a whole-person clinical assessment- Gather information from outside sources (especially other care providers)- Assess both behavioral and physical health conditions through a thorough history and physical examination- Capture conditions not yet diagnosed, including by ordering additional studies as indicated- Organize the information in a manner that supports successful disability applications (if appropriate)- Conduct visits in the field or in an individual's home when needed- Make individualized recommendations and/or referrals for programs/care provided by firsthand or outside providers, based on the assessed needs.RESPONSIBILITIES- Lead the medical component of the team-based care provided, including:- Training and advising firsthand Guides and Community Resources Guides on clinical issues and treatments- Support Guide Team on care coordination- Lead care management - identifying actionable care gaps- Perform medication reconciliation post-discharge and as needed- Communicate and coordinate with individual care providers, primarily at CMHCs, FQHCs, and hospitals.QUALIFICATIONSMaster's degree or higher3+ years of experience in ALL of the following:Value Based CarePrimary CareValid Nurse Practitioner (NP) certification/license in the state of Ohio (OH)Home visits are a major component of this job. Are you okay visiting patients in their homes?PreferredDo you have HCC Coding experience?BENEFITSA range of healthcare benefits offerings for yourself and/or your family401(k) with employer matching programCompetitive and flexible paid time off policiesChoice of Mac or PC for laptop or tablet as needed.