Overview
Our client is changing the way individuals living with Serious Mental Illness (SMI) get care. They are focusing on delivering real outcomes for a cohort that has historically been underserved, stigmatized, and deprioritized. By building a service focused on whole-person care, and aims to find, establish a trusting relationship with, and support quality care for individuals living with complex experiences of SMI.
The licensed Nurse Practitioner who leads the medical aspects of team-based care for individuals with serious mental illness that we serve. This position is responsible for documenting and supporting the medical needs of the individual, by performing a whole-person clinical assessment to identify and remediate care gaps. On an ongoing basis, this position will support care coordination among the individual's medical and behavioral health providers, making referrals as appropriate, as well as provide clinical support to Guides (peers) and Community Resources Guides (social workers).
You will:

• Perform a whole-person clinical assessment, including:
• Gathering information from outside sources (especially other care providers)
• Assessing both behavioral and physical health conditions through a thorough history and physical examination
• Capturing conditions not yet diagnosed, including by ordering additional studies as indicated
• Organizing the information in a manner that supports successful disability applications (if appropriate)
• Conducting visits in the field or in an individual's home when needed
• Making individualized recommendations and/or referrals for programs/care provided by the client or outside providers, based on the assessed need

Lead the medical component of the team-based care provided, including:

• Training and advising the client's Guides and Community Resources Guides on clinical issues and treatments
• Supporting Guide Team on care coordination
• Leading care management - identifying actionable care gaps

• Performing medication reconciliation post-discharge and as needed
• Communicating and coordinating with individuals' care providers, primarily at CMHCs, FQHCs, and hospitals

Requirements
Qualifications
Required

• Master's degree or higher
• 3 years of experience in ANY of the following:

• Primary Care
• Value Based Care
• Valid Nurse Practitioner (NP) in the state of Virginia (VA)

As an ideal candidate for this position, you will possess:

• A deep sense of empathy, compassion, and a naturally approachable demeanor
• Exceptional listening, communication, and interpersonal skills
• A genuine desire to assist those in need and support their journey towards wellness
• Comfort and enthusiasm for working within a multidisciplinary team, embracing a diverse range of roles and responsibilities, including direct service, teaching, and care management
• Cultural humility, a strong understanding of trauma-informed care, and awareness of social determinants of health
• A passion for providing data-driven care

• Familiarity with local healthcare providers
• The ability to maintain professional boundaries while effectively engaging with a challenging population in unconventional work environments
• Proficiency with computers and the Microsoft Office Suite
• A valid driver's license, private auto insurance to eligibility for coverage

The experience you bring to this role includes:

• Over 5 years of clinical care as a Nurse Practitioner, ideally within a primary care setting
• Experience working with and managing underserved populations facing challenges such as behavioral health and/or substance use disorder (SUD) conditions
• A proven track record of developing and delivering educational programs to nurses and affiliated medical staff
• Expertise in care management and coordination

Benefits
Our client's benefit design is in line with our values of compassion and empathy:

• A range of healthcare benefits offerings for yourself and/or your family
• 401(k) with employer matching program
• Competitive and flexible paid time off policies
• Choice of Mac or PC for laptop or tablet as needed