Nurse Practitioner Telehealth Ohio

Overview

This role offers an opportunity to care for and manage medically complex Medicaid and Dual-Eligible populations in Ohio. You will provide advanced practice care virtually while guiding an interdisciplinary team to improve patient outcomes and reduce hospital visits. The position combines clinical expertise with leadership and program development in a home-centered, value-based care model. Key Responsibilities Deliver high-quality virtual clinical care and ongoing management for medically complex Medicaid and Dual Eligible members Conduct patient assessments, medication management, care planning, and follow-up through telehealth and remote care technologies Coordinate care with primary care providers, specialists, managed care organizations, and community partners Lead and document advance care planning and goals-of-care conversations with patients and families Ensure accurate and compliant clinical documentation supporting HCC coding, risk adjustment, and quality initiatives including STAR and HEDIS gap closure Assist with hospital admission and discharge planning, ensuring smooth transitions back to the home setting Contribute to the development and continuous improvement of clinical protocols, operational processes, and value-based care strategies Schedule and Shift Details Participate in a rotating 24/7 triage and after-hours support model Must live in Ohio "Ideal Background" • Active Ohio Nurse Practitioner license (or ability to obtain licensure). • Family Nurse Practitioner (FNP) or Adult-Gerontology Nurse Practitioner (AGNP) certification required. • Minimum of 3–5 years of advanced practice clinical experience. • Comfortable practicing autonomously with full prescriptive authority. • Significant experience with telehealth, virtual care, or remote patient management. • Experience working with medically complex adults, elderly populations, individuals with disabilities, or home-based care models. • Working knowledge of value-based care, HCC coding, risk adjustment, quality gap closure, STAR ratings, and HEDIS measures. • Experience conducting advance care planning and goals-of-care discussions with patients and families. • Entrepreneurial mindset with the ability to thrive in a dynamic, startup-like environment. Screening Questions 1) Do you have a current Ohio Nurse Practitioner license or the ability to obtain one? 2) Are you certified as a Family Nurse Practitioner (FNP) or Adult-Gerontology Nurse Practitioner (AGNP)? 3) Do you have DEA registration and full prescriptive authority? 4) How many years of Nurse Practitioner experience do you have? 5) Can you describe your experience with telehealth or virtual care delivery? 6) Are you comfortable participating in a rotating 24/7 triage and after-hours support model? 7) Do you have experience working with medically complex Medicaid or Dual Eligible populations? 8) Are you familiar with HCC coding, risk adjustment, STAR ratings, or HEDIS performance measures? 9) Please also inquire about whether or not they have a Medicare and Medicaid number, and any health plans they are credentialed with. "What You'll Be Doing" • Provide comprehensive care management for medically complex Medicaid and Dual Eligible (D-SNP) members through telehealth and remote monitoring. • Collaborate with physicians, registered nurses, social workers, therapists, caregivers, primary care providers, managed care organizations, and community partners. • Participate in a shared 24/7 clinical triage and support rotation designed to prevent avoidable emergency department visits and hospitalizations. • Guide patients and caregivers through care transitions, including hospital-to-home coordination and advance care planning discussions. • Support quality improvement initiatives through accurate HCC coding, risk adjustment documentation, and closure of quality gaps, including STAR and HEDIS measures. • Help develop and refine clinical workflows, performance standards, and best practices as the Ohio program expands. • Foster strong relationships with patients, families, caregivers, and community partners while mentoring and supporting fellow clinicians. At HarborWell Health, we believe some of the most vulnerable patients in our healthcare system deserve more than reactive care—they deserve proactive, coordinated support that helps them remain safe, healthy, and independent in their homes. The populations we serve often include frail older adults, individuals with physical disabilities, and those with intellectual or developmental disabilities. These patients frequently receive home and community-based services and rely on multiple caregivers and support systems to meet their daily needs. Yet too often, early warning signs of declining health go unnoticed or unaddressed until they become emergencies. A caregiver may notice a patient has missed several meals, is becoming increasingly weak, or is developing swelling in their legs. While these observations are critical, there is often no clear pathway for rapid clinical intervention. As a result, small issues can escalate into emergency department visits, hospitalizations, and preventable health crises. HarborWell Health was founded to change that. Our vision is to transform the home into an engine of care by creating a physician-led, interdisciplinary clinical team that works alongside patients, caregivers, primary care providers, health plans, and community-based organizations. We build trusted, longitudinal relationships with members and intervene early—before problems become emergencies. Rather than replacing a patient's primary care provider, HarborWell serves as an extension of the care team. We provide high-touch clinical support between office visits, helping patients navigate complex medical and social needs while ensuring primary care providers remain informed and engaged. Our model is built around frequent patient engagement, collaboration with caregivers, virtual care, care coordination, and proactive clinical oversight. We focus on the fundamentals that often determine whether a vulnerable patient remains stable at home: medication adherence, nutrition, hydration, activity, sleep, and timely intervention when concerns arise. By partnering closely with the organizations and caregivers already serving patients in their homes, we create a more connected and responsive care ecosystem. Together, we help identify issues earlier, coordinate care more effectively, and reduce avoidable emergency department visits and hospitalizations. Our ultimate goal is simple: maximize safe days at home for every member we serve. For clinicians who join HarborWell Health, this is an opportunity to practice medicine differently—to build meaningful relationships, intervene before crises occur, and help transform the way care is delivered to some of the nation's highest-need populations.

Qualifications

• Master's degree or higher
• ANY of the following valid licenses/certifications:
  • Family Nurse Practitioner (FNP) in Ohio (OH)
  • Adult Gerontology Nurse Practitioner (AGNP) in Ohio (OH)
• Primary Care (3+ years)

Benefits

Company

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