Mobile Registered Nurse – I-SNP

Avail Health•Laurel, MD

2d•$90,000 - $110,000•Hybrid

About The Position

The Mobile Registered Nurse (RN) delivers high-quality, patient-centered nursing care to Institutional Special Needs Plan (I-SNP) members residing in long term care skilled nursing facilities (SNFs). This role focuses on proactive clinical support, early identification of condition changes, care coordination, and patient advocacy for a frail, medically complex population. This is a full-time W-2 position with a defined end date of December 2026. This role is aligned to current program needs, with the potential for extension based on business requirements and performance. The RN partners closely with Nurse Practitioners (NPs), Care Coordinators (CCs), facility staff, and the broader interdisciplinary team to improve clinical outcomes, reduce avoidable hospitalizations, and enhance quality of life while supporting effective utilization of healthcare resources. This is a highly collaborative, patient-facing role that requires strong clinical judgment, effective communication, and the ability to translate clinical findings into actionable care plans. The RN partners closely with Avail Health operations to support efficient scheduling, timely and accurate documentation, and overall program execution, including alignment with Medicare Advantage and I-SNP requirements. In addition, the RN conducts Health Risk Assessments in collaboration with members and, when appropriate, their authorized representatives identify clinical and social risk factors. Based on these assessments, the RN develops individualized care plans - including problems, goals, and interventions - that inform care coordination efforts and support the interdisciplinary team responsible for ongoing member care. Success in this role requires comfort working independently in the field, adaptability in a dynamic environment, and a proactive approach to continuous improvement and program development.

Requirements

Associate Degree in Nursing (ADN) from an accredited program required; Bachelor of Science in Nursing (BSN) preferred
Current, unrestricted Registered Nurse (RN) license in Maryland, maintained in good standing and in compliance with all applicable state regulations throughout employment
Minimum of 1–3 years of clinical experience required, preferably in geriatrics, long-term care, skilled nursing facilities (SNFs), home health, or other post-acute care settings
Demonstrated experience working with medically complex, high-risk, or frail elderly populations
Strong clinical assessment skills with the ability to identify subtle changes in condition and escalate appropriately
Excellent communication and interpersonal skills, with the ability to effectively engage patients, families, facility staff, and interdisciplinary team members
Proficiency with electronic health records (EHRs) and comfort working in technology-enabled care models
Strong organizational and time-management skills, with the ability to manage a mobile schedule across multiple facilities
Ability to work independently in a field-based setting while maintaining close coordination with a remote interdisciplinary team
Residence in Maryland with ability to travel within the assigned regions as needed
Authorization to work in the United States

Nice To Haves

Experience in value-based care models, including Medicare Advantage and/or I-SNP populations
Familiarity with care transitions, chronic disease management, and post-acute care workflows
Exposure to risk stratification, quality metrics, and HEDIS/STARS measures
Experience supporting interdisciplinary care planning and coordination across multiple care settings
Prior experience in mobile care delivery or community-based care models

Responsibilities

Provide in-person nursing assessments for I-SNP members, including routine wellness checks, post-acute follow-up, and condition-specific evaluations
Conduct comprehensive Health Risk Assessments (HRAs) to identify clinical, functional, behavioral, and social determinants of health needs
Assist in the development, implementation, and ongoing updating of individualized care plans in collaboration with NPs and the interdisciplinary care team
Monitor and document changes in patient condition, identifying early signs of clinical deterioration and escalating appropriately
Support Nurse Practitioners in care delivery by gathering clinical data, performing focused assessments, and facilitating timely interventions
Coordinate care across interdisciplinary teams, including facility staff, specialists, rehabilitation services, and family members
Assist with transitions of care, including admissions, readmissions, and discharges, ensuring continuity and accuracy of care plans
Perform medication reconciliation and support medication adherence through patient and caregiver education
Provide patient, family, and caregiver education on disease management, treatment plans, and goals of care
Support chronic disease management and preventive care initiatives for high-risk populations
Participate in interdisciplinary care plan meetings and contribute nursing insights to care planning
Facilitate communication between patients, families, facility staff, and providers to ensure aligned, coordinated care
Assist in reducing avoidable hospitalizations through proactive monitoring and timely intervention
Document all patient interactions accurately and in a timely manner within the electronic medical record (EMR)
Ensure compliance with I-SNP program requirements, regulatory standards, and organizational protocols

Benefits

401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements
Employees may be eligible for a discretionary performance bonus based on individual performance, role-specific metrics, and overall company performance. Bonus structure and targets vary by role and are not guaranteed. Employees must be actively employed on the payout date to receive any bonus.
Compensation is reviewed annually and may be adjusted based on performance, market data, and organizational factors. Adjustments are not guaranteed.
$0.725 per mile for travel exceeding 30 miles per day, up to $200 per day.
Comprehensive benefits include medical, dental, and vision coverage. The company offers a Direct Primary Care (DPC) model paired with a high-deductible health plan and covers 100% of employee medical premiums, with dependent coverage subsidized. Additional benefits include company-paid life and disability insurance, and employer contributions to a Health Savings Account (HSA).
Employees accrue 15 days of paid time off annually, increasing with tenure. PTO accrues per pay period.
8 paid company holidays plus 1 floating holiday annually.
401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements
Avail Health provides all necessary devices for clinical and technology-related activities
Professional liability and malpractice insurance coverage ($1M/$3M) provided