Become a part of our caring community and help us put health first
 

The Nurse Practitioner applies advanced education and clinical competencies to achieve optimal patient outcomes. The Nurse Practitioner works on problems of diverse scope and complexity ranging from moderate to substantial.

Program Overview: The Integrated Home Care Program is a dynamic and innovative initiative dedicated to transforming healthcare delivery for high-risk patients in the comfort of their own homes. We strive to significantly reduce avoidable hospitalizations and readmissions by providing comprehensive, patient-centered care to individuals with medical complexity and functional limitations. Our multidisciplinary team delivers proactive, coordinated care directly where our patients need it most.

Purpose of the Role: As an Advanced Practice Provider (APP) within our Integrated Home Care Program, you will play a pivotal role in enhancing the well-being of frail, medically complex, and often homebound patients. You will conduct comprehensive in-home assessments, develop individualized treatment plans in close collaboration with our dedicated care team, and leverage both in-person and telemedicine capabilities to deliver exceptional care. Your expertise will directly contribute to enhancing patient outcomes, reducing acute care utilization, and fostering a higher quality of life for our vulnerable patient population.

Key Responsibilities:

• Conduct comprehensive in-home evaluations and examinations: Perform thorough assessments of enrolled patients, focusing on their medical, functional, and psychosocial needs.
• Develop and implement personalized treatment plans: Collaborate and co-manage with primary care physicians and other members of the interdisciplinary team to create and execute effective treatment strategies tailored to each patient's unique circumstances. Co-management with the patient’s PCP.
• Educate and empower patients and families: Provide clear, concise education about their conditions, treatment options, medications, and the benefits of the Integrated Home Care Program, empowering them to actively participate in their care.
• Manage acute clinical issues in the home: Diagnose and treat urgent conditions, such as pneumonia, CHF/COPD exacerbations, UTIs, etc. Safely and effectively administer and monitor medication administration in the home setting, adhering to established protocols and ensuring patient safety.
• Maintain accurate and timely documentation: Thoroughly document all home visits, assessments, interventions, and communications within our Electronic Medical Record (EMR) system (Athena, Q4 2025).
• Participate actively in medical team meetings: Contribute to collaborative discussions, share insights, and participate in care planning during regularly scheduled team meetings on a rotating basis.
• Patient engagement: Based on coverage area, carry a caseload of ~45 patients in a given month, ~200 unique patients per year, completing 6-8 visits per day, establishing a weekly or every-other-week cadence of visits with patients in the caseload.
• Share after-hours call responsibilities: Provide timely and effective telemedicine consultations to patients and families as part of a rotating on-call schedule.

Use your skills to make an impact
 

Required qualifications:

• Nurse Practitioner or Physician Assistant with 5 + years of experience in Acute care, Geriatrics, Home Health, or a related field.
• Demonstrated passion for working with geriatric patients and their families in the home setting, with a strong commitment to providing compassionate and patient-centered care. Comfortable with end-of-life discussions when appropriate.
• Proven experience in ordering, managing, and monitoring medications in the home setting.
• Exceptional communication, interpersonal, and active listening skills, with the ability to build rapport and trust with patients, families, and colleagues.
• Ability to thrive in a collaborative, multidisciplinary team environment, contributing your expertise and working effectively with diverse professionals.
• Proficiency in using Electronic Medical Record (EMR) systems for accurate and efficient documentation.

Work Schedule:
* Regular business hours: Monday through Friday, 8:00 AM to 5:00 PM.
* After-hours call is shared equitably among the direct patient care team.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, know