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Chronic Care Outreach Clinician

Company: Monroe Plan for Medical Care
Location: Buffalo
Posted on: June 12, 2021

Job Description:

Want to be a part of an amazing organization? An organization that makes a difference in the lives of individuals each and every day?

Monroe Plan for Medical Care is a not-for-profit health care services organization that has been meeting the needs of our members in the Greater Buffalo, Rochester, Syracuse, and Binghamton Regions for nearly 50 years. Monroe Plan provides health home services and other critical health care services to individuals covered by Medicaid, Child Health Plus and the Essential Plan.

Following our mission and vision to improve the health status of individuals and families, Monroe Plan's innovative clinical care management programs are structured to meet the unique needs of members, providers, health care organizations and the communities we serve. Monroe Plan has consistently been recognized as a national leader in the "safety net" area, with a proven track record of improving health outcomes and reducing disparities by supporting a health care delivery system that ensures the availability of high quality medical care for all.

Chronic Care Outreach Clinician

Grade 312


This position will provide gaps in care screenings to members identified as having chronic conditions such as Diabetes, Hypertension/Cardiovascular Disease, COPD and Severe and Persistent Mental Illness. In collaboration with the member's assigned PCP, the incumbent will conduct a home visit to assess and provide any necessary services and screenings to close gaps in care. This position is highly independent and is 100% in the field.


% of Time

Essential Function


Conduct Gaps in Care Screenings and Member Education

  • Identify members with gaps in care for whom a home visit would facilitate meeting the gap/s in care.
  • Conduct a home visit with the identified member to perform all necessary gaps in care screenings to include:
  • Comprehensive Diabetes Care: eye exams
  • Spirometry Testing in the Assessment of COPD
  • Metabolic Monitoring for children and adolescents on Antipsychotics
  • Colorectal Cancer screening
  • Chlamydia Testing for sexually active women
  • Blood Pressure readings
  • Diabetes Screening for individuals with Schizophrenia or Bipolar Disorder who are currently taking Antipsychotic medications
  • HIV Viral Load testing
  • HbA1c testing
  • Ensuring medication adherence (statins, antipsychotics, blood pressure, asthma)
  • Order all applicable labs and tests as needed as determined by the screening
  • Provide education on chronic conditions and Health Home Care Management Services
  • Provide link to Monroe Plan CMA and/or to Monroe Plan Case Management to ensure the member is linked to appropriate community services to address SDoH and identified barriers
  • Document all telehealth transitional care visits within Case Trakker
  • All documentation should meet regulatory compliance and address errors/omissions to ensure billing is accurate and concise



  • Collaborate with member's assigned PCP to determine which chronic conditions will be managed and what applicable screenings will be done with the member
  • Update assigned PCP with the findings of the visit(s) and also ensure that all laboratory reports and test results are forwarded to the assigned practice
  • Collaborate with assigned PCP on findings of the visit(s) and test result(s) for the coordination of needed follow up care and services

Total must equal 100% - essential functions should be completed at least 10% of the time


  • Identifies opportunities to improve processes and services. Shares with Chief Medical Officer issues that are obstacles to providing great care and service
  • Attend regularly scheduled department and intradepartmental meetings
  • Performs other duties as assigned

MINIMUM REQUIREMENTS/LICENSES/CERTIFICATIONS - NYS Licensed Nurse Practitioner or Physician Assistant

  • 3-5 years Family Medicine or Internal Medicine experience
  • Ability to be independently credentialed for the Molina Provider panel (if NP)
  • 3-5 years behavioral health experience preferred
  • Previous experience in home care, conducting home visits preferred
  • Ability to work independently
  • Highly collaborative
  • Effective and diplomatic oral communication skills. Good listening skills
  • Sound reasoning and problem-solving skills
  • Strong computer skills
  • Ability to read, understand and follow written policies and procedures
  • Able to work effectively with a multidisciplinary team
  • Ability to learn new skills
  • Ability to interact with individuals with diverse cultural and religious customs
  • Current, unrestricted NYS Drivers License
  • Personal vehicle for reliable transportation PREFERRED QUALIFICATIONS
  • Experience in insurance industry. Managed Medicaid experience a plus

PHI MINIMUM NECESSARY USE: This staff position PHI access will be determined based on Minimum Necessary standards. The Minimum Necessary Grid can be found on the Human Resources and Compliance Web pages.

This job description is only a summary of the typical functions of the job, not an exhaustive or comprehensive list of all possible job responsibilities, tasks and duties. Additional responsibilities, tasks and duties may be assigned as necessary.

Monroe Plan for Medical Care is an Equal Opportunity Employer

Keywords: Monroe Plan for Medical Care, Buffalo , Chronic Care Outreach Clinician, Other , Buffalo, New York

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