At Diverge Health we are a team of entrepreneurs passionate about improving health access and outcomes for those most in need. We partner with primary care providers to improve the engagement and management of their Medicaid patients, providing independent practices access to specialized resources and clinical programs to address medical, social and behavioral patient needs. Our care ecosystem is equipped with enhanced technology and data interfaces to enable provider and patient success in a value-based environment. Guided by our core values of humility, continuous learning and feeling the weight, our team is on a mission to strengthen communities from within, unlocking people's ability to live their healthiest lives. 

We are looking for an experienced Nurse Practitioner to join our quickly growing team in Southeast Michigan! This role is critical to organizing, supporting, and providing clinical oversight within a multi-disciplinary care team. As a humble, experienced clinician, this individual will be a continuous learner excited about educating, mentoring, and providing clinical support and guidance to a growing team of community health coaches. The Nurse Practitioner will be collaborative, comfortable with the ambiguity that comes with an early stage, rapidly developing business, and excited about driving a population health approach for the patients we serve.  

What you’ll do 

As a Nurse Practitioner at Diverge you will guide the clinical operations and strategies of our care team, collaborating with our partner primary care providers and broader market team to ensure the delivery of patient outcomes through the Diverge model of care. While this role is not heavily patient facing, the Nurse Practitioner will ensure the delivery of high-quality patient care, efficient medical management, and effective utilization of healthcare resources, delivered by providing clinical support and guidance to our community health coaches. The Nurse Practitioner is responsible for providing medical expertise, clinical oversight, and strategic direction to enable success improving the health engagement and management of a population.  

Key areas you’ll add value: 

• Serve as the clinical supervisor of an interdisciplinary care team, overseeing chronic condition management, education, care plan development, self-management coaching, social support, and medical escalations with minimal direct patient care involvement  
• Effectively build trust with our partner primary care providers, acting as a liaison between them and our care team; demonstrate sound discernment around appropriateness of engagement and escalation across a wide range of patient needs and issues.  
• Bring an adeptness at technology system navigation, procuring patient data from different EMR systems to be analyzed and leveraged by Diverge care team in patient engagement, assessment, and care plan formulation.   
• Oversee care team performance by monitoring productivity, quality and patient outcomes while proactively identifying emerging complications and rising risks and partnering with PCP partners around appropriate escalations. 
• Monitor ER hospitalization data feeds, adjust patients risk levels, arrange post-discharge follow-up appointments, and analyze utilization and quality metric trends to develop targeted interventions in collaboration with market leadership and partner PCPs as necessary.  
• Embrace a role in education and training across our interdisciplinary care team; participate in training and support the delivery of ongoing education of health coaches, incorporating emerging patient and population trends and updates to the internal model of care to support consistent delivery of patient outcomes.  
• Perform chart reviews for medium and higher risk patients being assessed for coaching. 
• Develop and support implementation of proactive care plans based on patients' needs and risk levels; conduct ongoing assessment and monitoring of patients’ chronic conditions. 
• Utilize a population health approach to a patient panel with evidence-based prioritization of patient needs and acuity.  
• Respond to clinical escalations from health coaches; triage based upon clinical need and escalate to PCP, local pharmacy, or other providers involved in care, as needed to ensure timely resolution of medical need. 
• Collaborate with partner primary care physicians to discuss medication regimen changes and address care gaps, communicating regularly regarding care plans and updates on patient progress. 
• Prepare for, convene and lead, weekly interdisciplinary team rounds, working closely with Market Medical Director to troubleshoot complex cases and bring solutions to Diverge care team and partner PCPs, supporting continuous learning. 
• Ensure accurate coding and documentation of patient interactions and interventions, individually and across our care teams. 

What you Bring  

• 5+ years' experience as a Nurse Practitioner in Family Medicine or Primary Care 
• Active, unrestricted license to practice in the state(s) of Michigan 
• Board Certified (ANCC or AANP) in “Family” or “Adult-Gerontology Primary Care” 
• Certified Diabetes Care and Education Specialist (CDCES)  
• 2+ years' experience in primary care and chronic condition management.
• Comfort using technology in context of care documentation as well as internal collaboration
• Data orientation; ability to utilize operational reports and dashboards to understand market and practice level trends in engagement and performance; experience leveraging a set of data elements to monitor performance  

Preferred Experience  

• Knowledge of accurate coding and documentation practices. 
• Fluency in Spanish  
• Experience working in a value-based environment of care 
• Prior experience working in a team-based care model
• Experience with Salesforce or other care management platforms  
• Familiarity with working with community health teams and resources (community health workers, health coaches, LCSWs, or other types of community health team members) is a plus. 

Personal Characteristics 

• Desire to lead, mentor and support a team  
• Ability to manage multiple projects simultaneously. 
• Strong sense of humility 
• Preference for a collaborative work environment; ability to work constructively as part of a multidisciplinary, multi-level team.
• Strong cultural competence; ability to connect empathetically with individuals with diverse backgrounds and circumstances.  
• Strong verbal communication, ability to speak with internal and external stakeholders such as partnered primary care physicians and their staff, patients, and community health coaches.  

_{Our Investors}

_{Diverge Health is funded by GV and incubated by Triple Aim Partners, which since 2019 has partnered with entrepreneurs to co-found and launch eight companies focused on improving the quality, experience and total cost of healthcare.}

_{At Diverge Health we believe that a diverse set of backgrounds and experiences enrich our teams and enable us to realize our mission. If you do not have experience in all areas detailed above, we encourage you to share your unique background with us and how it might be additive to our team.}

_{Special Considerations} 

_{Diverge Health is dedicated to the principles of Diversity, Equity and Inclusion and Equal Employment Opportunities for all employees and applicants for employment. We do not discriminate on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identify or expression, or any other characteristic protected by the federal, state or local laws. Our decision to hire, promote, discipline, or discharge, will be based on merit, competence, performance and business needs.}