Community Health Family Nurse Practitioner

About the Role
Vanna Health is seeking an experienced, recovery-focused Family Nurse Practitioner (FNP) who is passionate about community care, health education and facilitating care that addresses all the dimensions of wellbeing. In this role, you will bring passion for serving individuals with mental illness and chronic physical health conditions, helping them access community-based care to improve health outcomes and quality of care for individuals in the New York City area.

This role focuses on conducting timely follow-up visits within 1 week of discharge from the emergency department (ED) or inpatient setting either in-person in the field or via telehealth, with the goal of reducing 30-day readmissions and ED re-presentations. The FNP will support member medication adherence through education, medication reconciliation and providing bridge prescriptions as needed. The FNP will also address barriers to care access, and will initiate or adjust medications for members experiencing challenges engaging with community providers. The role includes offering same-day urgent visits to help avoid unnecessary ED utilization, optimizing chronic disease management for high utilizers with complex conditions, facilitating preventive care and participating in complex case reviews. The FNP will play a key role in care coordination, working closely with Vanna Health’s interdisciplinary team to ensure continuity of care, address medical and behavioral health needs, and support engagement with outpatient services.

Responsibilities
Deliver direct clinical care in-person in the community, including member homes or via telehealth, including:

Conduct post-discharge follow-up visits within 7 days for eligible members

Perform comprehensive clinical assessments, including medical and behavioral health needs

Conduct annual wellness visits for eligible members

Prescribe and administer long-acting antipsychotic medications and monitoring of vital signs

Conduct specified point-of-care screening and laboratory testing

Develop and implement care plans in collaboration with an interdisciplinary team

Coordinate care with internal team members, including RNs, physicians, coaches, community health workers, and peer specialists

Liaise with external outpatient providers and payer care managers to ensure continuity of care and appropriate follow-up

Identify and address barriers to care, including social determinants of health

Support efforts to reduce 30-day ED re-visits and hospital readmissions

Ensure members are up to date on preventive care and screenings (e.g., breast cancer screening, annual eye exams for members with Diabetes Mellitus, Diabetes screening for members taking antipsychotic medication, colorectal cancer screening)

Document all encounters and care coordination activities in a timely and compliant manner

Participate in team meetings, case reviews, and quality improvement initiatives

About You
Need to Haves
Active and unencumbered New York State Nurse Practitioner license in good standing with prescriptive authority

Board certification as a Family Nurse Practitioner (FNP-C)

Ability to obtain credentialing with Optum

Experience working with complex patients, including those with mental illness, substance use disorders, and multiple medical comorbidities in the outpatient setting

Demonstrated experience working in interdisciplinary care teams

Strong care coordination, communication, and organizational skills

Ability to work independently in both field-based and telehealth settings

Willingness to learn how to work with Google, Slack, and Vanna EHR tools

Basic computer and phone skills

A valid driver’s license

Belief that individuals suffering from mental illness can and will recover to achieve life goals when provided the opportunity, support, and community

Nice to Haves
Multi-state licensure

Credentialed with New York State Medicaid

Experience in transitional care, care management, or population health

Familiarity with Medicaid populations and value-based care models

Experience conducting home visits or community-based care

Background in collaborative care