CenterWell Senior Primary Care

Pharmacist

• Use evidence-based medicine and clinical judgment to evaluate the suitability of pharmacotherapy for high-risk patients with chronic conditions, including diabetes, hypertension, heart failure and COPD
• Execute clinical protocols as allowed per organization and state regulatory agencies
• Optimization of drug coverage benefits for appropriate care and reduced costs (preferred formulary products, lower cost alternatives and home delivery pharmacy)
• Collaborate with physicians, nurses, and other healthcare professionals to optimize patient care
• Participate in high-risk rounds with a multi-disciplinary team to discuss patient progress and adjust treatment plans
• Excellent patient counseling skills and the ability to communicate complex medical information to patients and healthcare providers
• Disease state education for patients on appropriate use of medications and self-management
• Engage in quality improvement initiatives aimed at enhancing medication safety and efficacy
• Post-discharge medication reconciliation for high-risk transition of care patients
• Document all activity within clinic EMR and other required pharmacy or clinical management systems
• Support CMS Stars and HEDIS quality measures for successful clinic performance
• Maintain accurate documentation of clinical interventions and patient care activities
• Conduct in-service education and training sessions for healthcare staff and develop and share educational materials related to pharmacotherapy
• Stay current with advancements in pharmacotherapy and clinical guidelines.
• Provide consultation to healthcare providers on complex medication management issues
• Respond to additional requests from the Primary Care Organization, providing support within the pharmacist's defined scope of practice to advance organizational goals.
• Address and implement targeted initiatives or priorities as directed by the National Director or Associate Directors of Pharmacy, according to best practices and regulatory standards.

Senior Integrated Clinic Pharmacist

Therapist

• Evaluate, direct and provide speech/language pathology service to patients in the home or facility
• Participate in the development and periodic review of the Plan of Treatment and Plan of Care
• Utilize professional skills and judgment in assessing and treating disorders of speech, voice, language, hearing and swallowing
• Administer and interpret diagnostic tests and applications of therapeutic treatments including audio logic screening
• Observe, record and report changes in the patient's condition and response to treatment to supervisor and/or the physician
• Provide instruction and training to patients in use of alternative communication systems when appropriate
• Provide counsel and instruction to patients, families and healthcare staff
• Maintain and submit documentation as required by the Company and/or facility
• Prepare and submit timely written reports of evaluations, visits, summaries, care plans, care coordination activities and progress reports as required by Company policy
• Participate in care coordination activities and discharge planning
• Maintain the highest standards of professional conduct in relation to information that is confidential in nature.

Speech Therapist – Home Health

Director

• plans for all aspects of payor contracted operations and oversees implementation, ensuring contractual obligations are met
• develops and oversees processes that are scalable and drive performance, efficiency, and alignment with organizational goals
• provides vision, direction, and leadership for large-scale implementation efforts that span functions and business segments
• serves as a key advisor to senior leadership on execution of operational initiatives related to payor contracts
• oversees the design and execution of operational strategies that advance organizational priorities and operational excellence and meet contractual obligations
• leads cross-functional teams in identifying opportunities, defining objectives, and implementing initiatives that deliver measurable business impact and meet contractual obligations
• develops operational implementation frameworks, governance models, and performance metrics to guide execution and accountability
• partners with executives and senior leaders to ensure initiatives are scalable, contractually aligned, and aligned with organizational strategy and long-term goals
• provides expert consultation on operational implementation methodologies, organizational design, and change management practices
• oversees resource planning, budget development, and implementation of best practices to achieve sustainable results
• leads development of communications, reporting, and executive updates to share outcomes, insights, and recommendations
• builds a culture of innovation, collaboration, and continuous improvement across departments
• exercises strategic judgment and decision-making to address complex challenges and ensure successful delivery of transformation outcomes at scale

Director, Payor Operational Readiness

• Plan and administer prescribed physical therapy treatment for patients
• Assess and document patients' physical strengths to support physician evaluation
• Develop and implement a rehabilitation program
• Provide PTAs and Home Health Aides with clear written care instructions

Home Health Physical Therapist – PRN

• Administer the physical therapy treatment plan to patients
• Administer non-complex active and passive manual therapeutic exercises, therapeutic massage, traction heat, light, cold, water, and electrical modalities to patients
• Document client records and submit clinical documentation to the office on time each week
• Attend educational meetings and coordinate department in-services
• Notify Physical Therapist or Branch Director of any equipment failures, lack of supplies, or staff or client changes
• Apply concepts of infection control and universal precautions in performing patient care activities

Home Health Physical Therapist Assistant

• Plan and administer prescribed physical therapy treatment for patients, working onsite in their homes, to attain highest level of physical function.
• Assess and document patients' physical strengths to support physician evaluation and guide treatment goals.
• Develop and implement a rehabilitation program consistent with physician's Plan of Treatment and the goals of the patient team.
• Provide PTAs and Home Health Aides with clear written care instructions and oversee their performance and documentation.
• Document patient observations, interventions, and evaluations promptly and thoroughly.
• Report patient progress to the physician, Clinical Manager, care team, patient, and family, and submit all required evaluations, plans, progress notes, and discharge summaries.

Home Health Physical Therapist

Clinical Operations

• designs and implements initiatives that optimize clinical operations and enhance care delivery across aligned area(s), or the organization
• works on problems of diverse scope and complexity ranging from moderate to substantial
• identifies strategic improvement opportunities, establishes operational priorities, and develops standardized processes and practices to support clinical operational effectiveness
• aligns operational processes with organizational goals, regulatory requirements, and industry best practices to ensure efficiency, quality, and sustainability in operations and service
• advises executives to develop functional strategies (often segment specific) on matters of significance
• exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision
• uses independent judgment requiring analysis of variable factors and determining the best course of action

Home Health Clinical Operations Strategy Lead

Physical Therapist

Data Engineer

• Oversee data processing architectures and solutions ensuring efficient conversion of structured and unstructured data to insights at enterprise scale
• Ingest data from internal and external sources using cloud native platforms and software development best practices
• Develop software tools using AI, ML, and big data to turn data into insights that improve member outcomes
• Lead the development of PCO Analytics' data warehouse using Medallion architecture and Kimball modeling
• Collaborate with partners to develop data governance frameworks and standards

Lead Data Engineer – Primary Care

• Assess/screen patient's daily living/work-related skills and develop therapeutic retraining programs with measurable objectives.
• Administer and interpret diagnostic and prognostic tests of function to patients in their homes or other settings.
• Confer with the patient's physician and other health care team members.
• Provide therapeutic treatment and instruction to patients.
• Review/expand retraining programs.
• Consult with other vocational team members to develop and implement vocationally oriented plans.
• Report patient status and progress to physician and rehabilitation staff.
• Participate in care coordination and discharge planning activities.
• Design community reintegration activities to assist clients.
• Recommend and/or design special adaptive equipment for clients.
• Supervise, instruct and evaluate Occupational Therapy Assistant and Home Health Aide performance.
• Accurately document patients' care observations, interventions and evaluation.

Occupational Therapist – Home Health

• Assess/screen patient's daily living/work-related skills and develop therapeutic retraining programs with measurable objectives.
• Administer and interpret diagnostic and prognostic tests of function to patients in their homes or other settings to assist the physician in evaluating the patient's level of function.
• Confer with the patient's physician and other health care team members and participate in development/revision of the Plan of Care Treatment.
• Provide therapeutic treatment and instruction to patients in accordance with physician orders to improve/restore strength, coordination, range-of-motion and function or teach compensation measures.
• Review/expand the retraining programs in a manner consistent with the behavioral goals of each patient and within the guidelines of the rehabilitation program as a whole.
• Consult with other vocational team members, as appropriate, to develop and implement vocationally oriented plans consistent with the needs and capabilities of patients.
• Report patient status and progress to the physician, rehabilitation staff, Clinical Manager, patient and family members.
• Participate in care coordination and discharge planning activities and act as a resource to other health care personnel in meeting patient's needs.
• Design community reintegration activities to assist the client in the physical reconditioning effort, and/or the psychological adjustment and coordinate the plan with members of the interdisciplinary team.
• Recommend and/or design special adaptive equipment for clients to improve residence or working environments or improve their participation in the rehabilitation program and/or community.
• Design/train staff and family members to carry out the retraining program including dressing, feeding, grooming and hygiene skills, participate in team and family educational meetings.
• Supervise, instruct and evaluate Occupational Therapy Assistant and Home Health Aide performance in implementing occupational therapy services.
• Accurately and thoroughly document patients' care observations, interventions and evaluation on the day services are rendered.
• Ensure that interim (verbal) orders received from the physician are accurately documented and implemented.
• Submit evaluation, treatment plans and discharge summary to the supervisor and care management staff.

• Assess/screen patient's daily living/work-related skills and develop therapeutic retraining programs
• Administer and interpret diagnostic and prognostic tests to patients
• Confer with physician and other health care team members to develop/revision Plan of Care Treatment
• Provide therapeutic treatment and instruction to patients
• Consult with vocational team members to develop vocationally oriented plans
• Report patient status and progress to the physician and others
• Participate in care coordination and discharge planning activities
• Design community reintegration activities
• Recommend design special adaptive equipment for clients
• Supervise, instruct and evaluate Occupational Therapy Assistant and Home Health Aide
• Document patients' care observations accurately
• Ensure interim orders from the physician are documented

Occupational Therapist – Home Health, PRN

• Administer the physical therapy treatment plan to patients
• Work onsite in patients' homes
• Administer therapeutic exercises, therapeutic massage, traction heat, light, cold, water, and electrical modalities
• Document client records and submit clinical documentation
• Attend educational meetings and coordinate department in-services
• Notify Physical Therapist or Branch Director of equipment failures or supply shortages
• Apply concepts of infection control and universal precautions

Physical Therapist Assistant – Home Health

• Plan and administer prescribed physical therapy treatment for patients, working onsite in their homes, to attain highest level of physical function
• Assess and document patients' physical strengths to support physician evaluation and guide treatment goals
• Develop and implement a rehabilitation program consistent with physician's Plan of Treatment and the goals of the patient team
• Provide PTAs and Home Health Aides with clear written care instructions and oversee their performance and documentation
• Document patient observations, interventions, and evaluations promptly and thoroughly
• Report patient progress to the physician, Clinical Manager, care team, patient, and family, and submit all required evaluations, plans, progress notes, and discharge summaries

• Manage the daily branch operations.
• Ensure operational efficiencies, quality of patient care, and regulatory compliance.
• Support business development and patient base growth and manage/develop people.
• Oversee the branch/clinical staff.
• Ensure the branch meets applicable Federal, State, and local laws regarding certification and licensure process.
• Responsible for long-range planning, fiscal viability, and quality of care provided by the branch.
• Recruit, interview and hire staff, and monitor quality care and organizational performance.
• Assist other disciplines in coordinating activities, assuming responsibility for continuity, appropriateness, and quality of services delivered.
• Develop, plan, implement, analyze and organize operations for the Branch.
• Deliver care for all patients served by the Branch by providing guidance and support to the Clinical Manager(s).

Senior Integrated Clinic Pharmacist

Speech Therapist – Home Health

Director, Payor Operational Readiness

Home Health Physical Therapist – PRN

Home Health Physical Therapist Assistant

Home Health Physical Therapist

Home Health Clinical Operations Strategy Lead

Physical Therapist

Lead Data Engineer – Primary Care

Occupational Therapist – Home Health

Occupational Therapist – Home Health

Occupational Therapist – Home Health, PRN

Physical Therapist Assistant – Home Health

Home Health Physical Therapist

Branch Director, Home Health