AbsoluteCare

AbsoluteCare AbsoluteCare is a value-based care organization serving high-risk Medicaid and Medicare populations across Ohio. We go BeyondMedicine to deliver whole-person care through interdisciplinary teams embedded in the communities we serve. The CKD CBP role is central to our mission of slowing disease progression, reducing avoidable hospitalizations, and meeting members where they are literally. Job Summary This role is primarily community-based, focusing on providing annual wellness visits to AbsoluteCare's community members in their homes. The annual wellness visits are conducted for the purpose of risk adjustment and quality gap closure, with an emphasis on clinical documentation excellence ensuring every chronic condition is documented with the specificity and clinical detail required for accurate risk adjustment. Most visits will be conducted in the member's home; visits may occasionally take place in the provider's home center. Upon mutual agreement, the provider may also work in the intermediate care area of their home center. Duties and Responsibilities Annual Wellness Visits & Clinical Assessment Perform community-based annual wellness visits in member homes as scheduled by the AbsoluteCare team. During scheduled hours without visits on the calendar, proactively contact members by phone to schedule and arrange upcoming annual wellness visits. Conduct comprehensive member assessments including Health Risk Assessment (HRA), depression screening (PHQ-2/PHQ-9), cognitive screening, functional status/ADLs, fall risk assessment, and advance care planning. Perform comprehensive medication reconciliation for adherence and appropriateness; review external prescription history. Provide member and family education on chronic disease self-management, preventive care, and available AbsoluteCare resources. Communicate the benefits of AbsoluteCare to the member and coordinate care with the center if desired Clinical Documentation Excellence Complete a detailed assessment and plan for each of the member's chronic conditions using the DSP framework (Diagnosis with specificity Status Plan) to support accurate risk adjustment and HCC capture Ensure annual recapture of all active HCCs with appropriate ICD-10 specificity and supporting clinical evidence (e.g., CKD stage, diabetic complications, heart failure type/class). Review diagnoses against the member's medication list to identify documentation opportunities and ensure clinical consistency (e.g., medications present without a supporting diagnosis, or diagnoses without an active treatment plan. Query the member's history for conditions that may be under documented or uncaptured, including SDOH needs. Quality Gap Closure Identify and address open quality care gaps during each visit (e.g., A1c testing, breast cancer screening, diabetic eye exams, blood pressure control) using PRISMA and pre-visit chart prep data. Ensure the correct AWV type is documented (Initial vs. Subsequent) and the appropriate AWV workflow/template is used in eCW. Document a preventive care plan and 5 10 year screening schedule, or reference in patient instructions. Review and update the member's care team (PCP, specialists, care coordination, community supports). Care Coordination & Communication Communicate member's medical conditions, mental health conditions, substance use, and SDOH needs to AbsoluteCare resources as discussed and agreed upon with the member. Offer intervention to at-risk members to avoid unnecessary hospitalizations. Coordinate with the center-based care team, CHWs, and community transitional care managers when member needs are identified during visits. Document appropriately in the Electronic Medical Record within required timeframes. Intermediate Care Area (as applicable) Upon mutual agreement, provide clinical services in the intermediate care area of the home center, supporting acute and episodic care needs as they arise Required Physician, Nurse Practitioner, or Physician Assistant with 2 or more years experience. Active, unrestricted state license and DEA; board certification (AANP, ANCC, or NCCPA). Valid driver's license and reliable transportation this role requires daily travel to member homes; mileage reimbursement provided. Proficiency with electronic medical records. Patient-centered, whole-person approach to care delivery Preferred Experience with risk adjustment, HCC coding, and clinical documentation standards (DSP/MEAT criteria) candidates without this background will receive structured training. Multi-setting background (hospital, urgent care, home-based, or community-based). Experience working with high-risk, medically complex populations with multiple comorbidities, including behavioral health and substance use conditions. Knowledge of Medicare AWV requirements and quality measure specifications (HEDIS, Star Ratings). Knowledge of local community resources, geography, and social determinants of health in the assigned market