Registered Nurse (RN) – ACO House Call Services

Essen Medical Associates•Bronx, NY

4d•Remote

About The Position

The Registered Nurse (RN) for ACO House Call Services is a critical member of the care team. You are expected to operate independently, identifying and serving patients’ needs, using your best judgment to help implement their care plan, or to escalate if and when you feel changes need to be made. In some cases, you will come to know the patient and their health status better than their PCP. Serving our highly vulnerable, highly complex population, you will complete independent as well as tele-assisted medical visits, conduct in-home clinical and risk assessments, facilitate care coordination, and educate patients and their families on their diagnoses, risks, and recommendations for healthier living. This role supports value-based care initiatives by improving care transitions, reducing avoidable utilization, closing care gaps, and enhancing patient outcomes through proactive, patient-centered home-based services.

Requirements

Active Registered Nurse (RN) license in the state of practice
Associate or Bachelor of Science in Nursing (BSN preferred)
Strong assessment, communication, and care coordination skills

Nice To Haves

Prior inpatient (med-surg, step-down, telemetry, ED) or home infusion experience (strongly preferred)
Experience in care management, home health, house calls, or population health
Experience with phlebotomy and/or placing IVs, especially difficult sticks
Experience with wound care
Experience working in an acute or emergency setting
Knowledge of CMS quality measures and care transition models
Familiarity with EHRs and mobile clinical documentation tools
Strong clinical judgment and independent decision making
Wound care experience and Experience managing foley and suprapubic catheters
Excellent interpersonal and patient engagement skills
Ability to work independently in home-based settings
Cultural competence and sensitivity to diverse populations
Strong organizational and time management skills
Ability to work collaboratively within interdisciplinary teams

Responsibilities

Conduct comprehensive in-home nursing assessments, including physical, psychosocial, functional, and environmental evaluations
Identify acute and chronic health issues, medication concerns, and safety risks in the home
Perform vital signs, health screenings, and condition specific assessments per protocol
Provide disease specific education (e.g., CHF, COPD, diabetes, HTN, Dementia, Fall-Risk)
Develop, implement, and update individualized care plans in collaboration with interdisciplinary teams
Coordinate care across primary care, specialists, behavioral health, home health, SNFs, and community resources
Support care transitions following hospitalizations, ED visits, and SNF discharges
Address social drivers of health (SDOH) and connect patients to appropriate community services
Perform medication reconciliation during home visits
Identify medication discrepancies, adherence issues, side effects, and potential interactions
Educate patients and caregivers on medication purpose, dosing, and safety
Communicate medication concerns to PCPs, pharmacists, and care teams
Support ACO quality measures, utilization reduction, and risk-based outcomes
Assist with closing quality care gaps
Document accurately to support clinical quality, risk adjustment, and compliance initiatives
Participate in addressing high utilizers and preventable readmissions
Document all visits and interventions accurately and timely in the EHR
Communicate findings and recommendations to PCPs and interdisciplinary care teams
Participate in case conferences, huddles, and quality improvement initiatives
Educate patients and caregivers on disease management, symptom monitoring, and when to seek care
Promote self-management, adherence to care plans, and preventative care
Support advance care planning and goals of care discussions as appropriate