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Job Description
Description
JOB RESPONSIBILITIES
Clinical Care Perform preventive care and wellness visits Complete referrals and coordinate specialty care Conduct hospital discharge follow-up visits within 7 days Manage ER follow-up appointments Close preventive care gaps Perform Annual Wellness Visits Manage chronic disease registries (diabetes, hypertension, COPD, CHF) Assist with patient messages and refill requests Support value-based care initiatives Care Coordination Collaborate with care managers, pharmacists, behavioral health providers, and community health workers Participate in quality improvement initiatives Assist with population health management Provide comprehensive primary care including evaluation, diagnosis, treatment planning, and follow-up for acute and chronic conditions. Perform health maintenance, preventive screenings, and patient education aligned with FQHC quality metrics (e.g., UDS measures). Order, interpret, and act on diagnostic tests, including labs, imaging, and specialty consults. Prescribe medications and durable medical equipment in accordance with licensure and state/federal regulations. Manage chronic diseases such as diabetes, hypertension, COPD, asthma, and behavioral health conditions using evidence-based guidelines. Participate in care coordination with behavioral health, dental, pharmacy, community health workers, and external partners. Provide urgent care or walk in same-day access services as needed. Maintain accurate, timely documentation in the electronic health record (EHR) consistent with billing and compliance standards. Team-Based Care & Collaboration Function as a physician extender, working closely with supervising/collaborating physicians to ensure continuity and quality of care. Participate in interdisciplinary team huddles, case reviews, and quality improvement initiatives. Collaborate with nursing staff, medical assistants, care managers, and community outreach teams to optimize patient outcomes. Support integration of behavioral health, social services, and population health strategies within the care model. Quality, Compliance & Performance Meet or exceed FQHC performance expectations including UDS quality measures, patient satisfaction, and productivity benchmarks. Adhere to
HRSA , CMS
, state licensing, credentialing and organizationalpolicies. Participate in peer review, chart audits, and ongoing professional development. Maintain compliance with infection control , HIPAA , and OSHAstandards. Engage in quality improvement projects and evidence-based practice initiatives. Requirements
JOB REQUIREMENTS
Current licensure as a Physician Assistant or Nurse Practitioner in the state of practice. Current DEA registration BLS Certification Experience in primary care, community health, FQHC, or underserved populations strongly preferred. Ability to work effectively in a team-based, patient-centered medical home (PCMH) environment. Strong commitment to health equity , access, and mission-driven care.
EDUCATIONAL REQUIREMENTS
National certification (NCCPA for PAs;
AANP/ANCC
for NPs). Valid DEA registration (or eligibility). Current BLS certification; ACLS preferred.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS
The work environment, physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions: Frequently able to move freely about facility with or without an assisted device, and must be able to perform the functions of the job as outlined in the job description. Overall dexterity is required including frequent handling, reaching, grasping, ability to address multiple complex problems simultaneously without loss of efficiency or accuracy. Constantly required to sit/stand/walk for long periods of time, ability to learn, remember, focus, categories, and integrate information for decision making, problem-solving and comprehending. Works in an office in a clinic environment with minimal exposure to noise, temperature discomfort and lighting inadequacies.
