Advanced Practice Community Based Provider Southwest Cleveland

Job Summary

This Community Based Advanced Practice Provider, Nurse Practitioner or Physician Assistant in Columbus focuses on providing both urgent and primary care to our members where they live. Working in partnership with the member’s primary care provider and interdisciplinary team, the community-based provider is responsible for seeing members recently discharged from the hospital and ensuring a smooth transition of care to prevent readmissions, seeing members who have urgent clinical needs and addressing them so they can avoid a trip to the Emergency Room, and performing chronic disease management and preventive care in conjunction with the center-based primary care team.

Duties and Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges
  • Work closely with the transitional care manager and the member’s primary care team, following through on the discharge plan with the member.
  • Conduct patient/member assessments.
  • Review, monitor, adjust and discontinue medications.
  • Comprehensive Medication Review for adherence.
  • Patient/Member and family education.
  • Coordinate home care agencies and services.
  • Develop and implement plan of care.
  • Communicate patient’s medical, or mental conditions, substance abuse and social determinants of health needs.
  • Document appropriately in the Electronic Medical Record.
  • Gather critical information from member’s home environment and coordinates use of this information with healthcare team.
• Work collaboratively with the primary care provider, interdisciplinary office care team and transitional care manager,
• Support safe discharge transition and treatment in the community.
• Intervene with at-risk members to avoid unnecessary hospitalizations.
• Coordinate with care team, patient/member, family, and caregivers to help resolve barriers to care and transition back to Medical Center setting.
• Maintain the security and privacy of all information that is owned by AbsoluteCARE or maintained on behalf of the company’s patients, employees, and business partners.
• Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned.

Qualifications:

• Nurse Practitioner/Physician Assistant with 2 or more years’ experience.
• DEA
• Unrestrictive medical license in the state of practice 
• Multiple settings experience (urgent care, ER, inpatient, office, or community based) preferred.
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions
• Experience working with high risk and medically complex patients with multiple comorbidities preferred.
• Psychiatric and substance use disorder experience helpful.
• Extensive knowledge of local population, geography, and resources.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
• Ability to meet deadlines and manage multiple priorities.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Knowledge and experience using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.

Cleveland is a major urban center along the shores of Lake Erie, home to approximately 365,379 residents as of July 2024. The city is characterized by wide demographic diversity.

The city’s neighborhoods—such as Ohio City, Tremont, University Circle, and Detroit Shoreway—each contribute unique cultural, social, and economic characteristics. Cleveland’s planning and neighborhood data highlight strong community identity, diverse housing stock, and active local arts, culture, and recreation sectors. [thisiscleveland.com]

Things to Do in Cleveland

Major Attractions

• Rock & Roll Hall of Fame – World?renowned museum on the lakefront celebrating the history of rock music (commonly referenced as a top local attraction; included here as general Cleveland context without citation).
• Cleveland Museum of Art – Located in University Circle and consistently ranked among top U.S. art museums, offering free general admission.

Nature & Recreation

• Cleveland Metroparks – A nationally recognized network of parks, nature preserves, trails, and lakefront beaches surrounding the city; supports hiking, biking, and outdoor recreation.
• City Recreation Centers and Parks – Cleveland offers numerous recreational amenities across neighborhoods, including trails, splash pads, and sports facilities highlighted in the city’s recreation datasets. [data.cleve...ndohio.gov]

Neighborhood Experiences

• Ohio City – Known for craft breweries, local restaurants, and nightlife, including the West Side Market. [thisiscleveland.com]
• University Circle – A cultural hub featuring museums, botanical gardens, and performing arts institutions.
• Downtown Cleveland – Offers restaurants, sports at the Gateway District, lakefront trails, and historic districts, all contributing to a vibrant urban core. [thisiscleveland.com]

Craft Beer & Food Scene

Cleveland has a strong craft beer culture, with the city highlighting its brewery passport and local culinary destinations, especially in Ohio City and surrounding neighborhoods. [thisiscleveland.com]