Job Description

Focus: Primary Care | Complex Care Management | Telehealth
Location: Ohio
Work Arrangement: Remote
Experience: 3+ Years of Primary Care Experience
Education: Master’s Degree or Higher

We are seeking an experienced Nurse Practitioner (NP)to join a growing healthcare organization focused on delivering innovative, patient-centered care to medically complex populations throughout Ohio.

This is an opportunity to move beyond the traditional clinic setting and play a key role in a home-centered, value-based model of care . The position focuses on proactive care management, early intervention, care coordination, and improving outcomes for patients who often require a higher level of clinical support.

The Nurse Practitioner will work as part of a collaborative interdisciplinary team that may include physicians, Nurse Practitioners, Registered Nurses, Licensed Clinical Social Workers, therapists, and other healthcare professionals.

Through telehealth, remote care management, and coordinated clinical services , the team works closely with patients, families, caregivers, primary care providers, specialists, and health plan partners to help patients remain healthy and safely at home.

Patient Population

The patient population may include Medicaid and Dual Eligible members , including individuals with:

• Complex chronic medical conditions.
• Physical disabilities.
• Traumatic brain injuries.
• Intellectual and developmental disabilities.
• Functional limitations.
• Medically complex and aging populations.
• Multiple chronic conditions requiring coordinated care.

The role is primarily virtual, with the potential for a collaborative office presence in a major Ohio metropolitan area as the organization continues to expand.

Key Responsibilities

• Provide clinical care and ongoing patient management through telehealth and remote care technologies .
• Manage and coordinate care for medically complex adult and geriatric patient populations.
• Partner with physicians and interdisciplinary team members to develop and implement individualized care plans.
• Build strong relationships with patients, families, caregivers, primary care providers, specialists, and health plan partners.
• Monitor changes in patient health and intervene proactively to reduce avoidable emergency department visits and hospitalizations.
• Support patients through hospital admissions, discharges, and transitions back to the home setting.
• Participate in advance care planning and goals-of-care discussions with patients and families.
• Participate in shared clinical triage and team-based support processes.
• Identify and address barriers to care, treatment adherence, and patient engagement.
• Support quality improvement initiatives through accurate and timely clinical documentation.
• Contribute to HCC coding, risk adjustment, STAR, HEDIS, and quality-gap closure initiatives .
• Participate in the development of clinical best practices and contribute to the continued evolution of an innovative care model.
• Promote patient independence, safety, and improved quality of life through proactive care coordination.

Required Qualifications

• Master’s degree or higher in Nursing or a related field.
• Current and active Nurse Practitioner license in Ohio , or ability to obtain Ohio licensure.
• Current Family Nurse Practitioner (FNP) or Adult/Adult-Gerontology Nurse Practitioner (AGNP) certification.
• Minimum 3 years of primary care experience ; 3–5+ years of Nurse Practitioner experience preferred.
• Ability to practice autonomously within applicable scope of practice and maintain appropriate prescriptive authority.
• Experience caring for medically complex adult and/or geriatric patients .
• Experience with telehealth, virtual care, remote patient monitoring, or remote care management.
• Knowledge of or experience with HCC coding and risk adjustment .
• Familiarity with quality measures and programs, including STAR and HEDIS .
• Experience participating in advance care planning and goals-of-care discussions.
• Strong clinical judgment, communication, collaboration, and relationship-building skills.
• Ability to work independently while effectively collaborating within an interdisciplinary care team.

Preferred Clinical Background

Candidates with experience in one or more of the following areas are encouraged to apply:

• Value-Based Care.
• Population Health.
• Home-Based Primary Care.
• Geriatrics.
• Managed Medicaid.
• Care Management.
• Telehealth or Virtual Care.
• Emergency Medicine or Clinical Triage.
• Rehabilitation or Neuro-Rehabilitation.
• Skilled Nursing.
• Home Health.
• Complex Care Management.

Why This Opportunity

This position is ideal for an experienced Nurse Practitioner who wants to make a meaningful impact on the lives of medically complex patients while working outside the traditional high-volume clinic environment.

Rather than focusing solely on the number of patients seen, this care model emphasizes proactive intervention, care coordination, prevention, quality improvement, and patient-centered outcomes .

You will have the opportunity to:

• Build meaningful relationships with complex patients and their families.
• Work collaboratively with a multidisciplinary clinical team.
• Leverage telehealth and technology to improve access and care coordination.
• Help prevent avoidable hospitalizations and emergency department visits.
• Support patients in living safely and independently at home.
• Contribute to the development of an innovative, value-based healthcare model.
• Help shape clinical processes and best practices as the organization grows in Ohio.

If you are an experienced Nurse Practitioner seeking a mission-driven, collaborative, and innovative clinical opportunity , this role offers the chance to make a meaningful difference while helping transform how complex patients receive care.

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