Advanced Practice Practitioner (NP/PA)

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Overview

Reporting to the Clinical Manager, the Advanced Practice Practitioner (NP/PA) is responsible for conducting patient visits, ensuring effective collaboration, proper clinical management, documentation of visits, and high-quality patient care delivery to Grace at Home family members. This role involves direct patient care in-person and via telehealth to meet organizational goals, improve member outcomes, and provide exceptional patient care. This position is accountable for ensuring Grace at Home is positioned to innovatively deliver on its promise. They should embody Care at Home’s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded. The Nurse Practitioner will have a strong knowledge base in providing care in the home, Value Based Care, HEDIS and Stars, documentation and coding, and medical practice principles. They will stay informed about advancements in healthcare practices and disseminate relevant knowledge.

Duties & Responsibilities

• Deliver comprehensive and follow-up care through in-home and virtual visits, including AWVs, Comprehensive Assessments, Follow-up visits, and TOCs (Transitions of Care) in accordance with Medicare, Medicaid, and commercial plan requirements.
• Practice value-based, home-centered care focused on quality, cost reduction, population health outcomes, and patient satisfaction.
• Provide ongoing management of acute and chronic conditions, collaborating with multidisciplinary teams to develop and implement individualized care plans.
• Participate in daily huddles and interdisciplinary team meetings to enhance patient care coordination.
• Prescribe medications, therapies, and lifestyle interventions within scope of practice.
• Communicate clearly and compassionately with Family Members, supporting prevention, chronic disease management, and health education.
• Provide on-call backup support to the nurse line in licensed states, requiring additional state licensure for cross-coverage.
• Maintain accurate documentation in the EMR and demonstrate proficiency with practice management systems.
• Ensure compliance with clinical ethics, HIPAA, and all applicable federal and state regulations.
• Participate in quality improvement initiatives, professional development, and other duties as assigned.

Qualifications

• Education/Experience: Master’s degree in nursing or related science field required
• Certification/Licensure: Active and unrestricted NP/PA license required in the state of hire.
• Clinical: 2+ years of direct patient care as a Nurse Practitioner strongly preferred. Community-based care experience preferred. Experience with Medicare/Medicaid is preferred
• 2+ years of clinical experience treating complex chronic conditions and high-needs patients, Medicare and LTSS experience preferred
• Excellent verbal, written, presentation, and group facilitation skills
• Must have strong critical analytic, thinking and communication skills
• Computer Knowledge: Excellent computer skills required particularly Microsoft applications including Word, Excel, PowerPoint, and Outlook. Willingness to explore and learn new or unfamiliar applications that may benefit the clinical team
• Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced organization.

The working environment and physical requirements of the job include:

Visits are conducted in patient homes as well as remotely via telehealth. Travel to patient home is required. Any In-office work is performed indoors in a traditional office setting with air conditioning, artificial light, and an open workspace. In this position you will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended per