Clinical Intake Home Visits -Nurse Practitioner/ Physician Assistant

Landmark Health
Los Angeles, California
May 28, 2021
Jun 27, 2021
Contract Type
Full Time
About Landmark Health

There is a care gap in America for those who need extra time with medical providers and easier access to care. Landmark cares for this group—people perhaps much like your parents, neighbors, and elders in your community—those with multiple chronic conditions.

Landmark Health is transforming how healthcare is delivered to patients with complex medical situations. As a national medical group, we provide home-based medical services to simplify care for those who need it most.

You will primarily assist in performing the initial visits to enroll patients into the Landmark program and to gather pertinent clinical information necessary for successful onboarding. Works with the Landmark Health Medical Director, Zone Director, Director of Health Services, Corporate Director of Health Services, and UM staff in the development and/or implementation of medical management policy, clinical protocols, utilization management guidelines, and quality management programs. Dedicated to improving the health and well-being of members, this position collaborates with the PCP, and as needed, the health plan Medical Director and other health professionals, to develop members’ goals of care in all phases of long-term care.


Territory: West LA / Downtown LA

Bilingual Highly Preferred


  • Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing.
  • Understands and complies with long-term care policies and procedures, including those that regulate nursing facilities and assisted living communities.
  • Establishes and maintains effective relationships with members and their legal representatives, facility staff, PCPs and other collaborating physicians/providers.
  • Performs an initial comprehensive assessment on all newly enrolled members. Develops a member management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with members and/or their legal representatives to review newly developed or modified care plans; involves the PCP in these meetings. Develops effective collaboration and communication with assigned longitudinal providers to provide for effective transition of care.
  • Completes follow-up and post-hospital assessments according to documented standard operating procedure.
  • Prescribes appropriate diagnostics and interventions to avoid unnecessary transfers/acute admissions.
  • Consults with hospital physicians following notification of member transfer.
  • Collaborates with UM staff and PCPs/facility staff to enable medical necessity determinations for requested medical services.
  • Educates members and/or their legal representatives in disease processes affecting members and ways to manage them effectively, as well as to promote wellness.
  • Provides counsel, support and education to facility staff.
  • Supports FCMs in developing and providing in-service educational programs to facility staff.
  • Participates in management meetings that include, but may not be limited to:
  • Weekly case conference reviews
  • Monthly staff meetings
  • Schedule Joint Operating Committee meet
  • Quarterly Quality Improvement Committee meetings
  • Continuing education/journal club programs
  • Implements HEDIS measure campaigns and other quality initiatives as directed by Corporate Health Services to ensure the highest standards of care and to promote the improvement of care management and delivery.
  • On-call for caseload during business hours. May require some participation in clinical on-call program as plan expands.
  • Keeps current on relevant medical and nursing research, technology, and related issues by attending continuing education courses, professional meetings and journal reviews.
  • Perform related duties as necessary and other duties as assigned.

          Completion of Nurse Practitioner (NP) or Physician Assistant (PA-C) accredited program2+ years of clinical NP or PA experience preferredKnowledge of clinical standards of careKnowledge of CPT, ICD-9 and HCPC codesAwaremess about UM standards, NCQA requirements, CMS quidelines, Millman guidelines, and Medicaid/Medicare contracts and benefit systems is helpfulCurrent unrestricted NP or PA state license, and current state driver’s licensePassion for delivering care to patients with complex, chronic illnessesWillingness to conduct house callsAccess to reliable transportation to conduct patient visits required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy.Bi-lingual Spanish preferred
In order to work with potentially vulnerable patient populations and to keep employees healthy while caring for patients, all patient-facing employees of Landmark must provide evidence of the following required immunizations/vaccinations as a condition of employment: TB, MMR, Tdap, and Influenza. Declinations may be accommodated based on your medical history, an allergy or religious beliefs. Please immediately contact HR if you wish to apply for an exemption from our vaccination requirements so that we may determine if you qualify for an accommodation.

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