Job Description

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description:

The Nurse Practitioner (NP)  is responsible for providing high-quality, patient-centered, comprehensive primary care. Utilizing Upward Health’s proprietary Facilitated Virtual Care platform, the NP delivers care that improves outcomes and reduces costs for patients with complex diagnoses and co-morbid, chronic conditions. This role primarily involves virtual patient care with periodic or as needed in-person care to support transitions of care, annual wellness visits, risk adjustments, primary care needs, and urgent visits. The NP collaborates closely with a multidisciplinary team to provide whole-person care to our patients in their homes.

Key Responsibilities:

• Triage, diagnose, and treat patients in person or via our virtual care platform.
• Serve as a day-to-day clinical leader, providing decision support and directing the multidisciplinary team under the guidance of the Medical Director.
• Conduct primary care, urgent visits, and annual wellness exams, ensuring all appropriate screening tests and quality measures are addressed.
• Refer patients appropriately for behavioral health and specialty services.
• Coordinate care transitions to prevent hospital readmissions by collaborating with PCPs, hospitalists, and SNF providers.
• Participate in the on-call provider schedule to support the 24/7 patient hotline, requiring after-hours and weekend availability on a rotating and recurring basis.
• Foster a collaborative working environment with all members of the interdisciplinary team, contributing to daily huddles, team meetings, and patient discussions.
• Monitor and respond to remote patient data collected through monitoring devices.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Perform and document accurate and thorough risk assessments for the purpose of accurate documentation of condition(s).
• Expertise in managing complex, polychronic patients, with demonstrated ability to assess and treat high-acuity patients.
• Familiarity with caring for Medicare and Medicaid populations, with experience in both inpatient and outpatient or home care settings.
• Proficiency in motivational interviewing, trauma-informed care, and supporting vulnerable populations is preferred.
• Excellent written, computer, and oral communication skills, with the ability to communicate efficiently and proactively with the clinical team.
• Dedication to health equity and transforming care for patients in their homes.
• Strong organizational skills and ability to provide clinical leadership and coordination.

Qualifications:

• Minimum of 5 years’ experience as a provider, with a minimum of 3 years in a primary care, or related, setting.
• Multi-state Advanced Nursing License or willingness to obtain.
• A valid driver’s license and auto liability insurance.
• Willingness and ability to travel as needed, though responsibilities are primarily performed virtually.
• Experience in urgent/emergent care settings is a plus.

Key Competencies:

Clinical Leadership:

• Ability to provide decision support and leadership to the care team.

Patient-Centered Care: 

• Focused on delivering high-quality, compassionate care to improve patient outcomes.

Collaboration: 

• Works effectively within a multidisciplinary team to provide comprehensive care

Adaptability: 

• Thrives in a dynamic, fast-paced environment with evolving protocols.

Problem-Solving: 

• Proactively identifies and addresses challenges in patient care and team coordination.

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

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