Nurse Jobs

About The Position

Requirements

• Current, unrestricted autonomous APRN license in the state where services are provided.
• Current National Board Certification as a Nurse Practitioner, such as AGNP, FNP, or Adult-Gerontology Acute Care, through ANCC or AANP.
• Master’s or doctoral degree in Nursing from an accredited advanced practice nursing program.
• Current Basic Life Support (BLS) certification.
• Active DEA registration and prescriptive authority matching state mandates, or eligibility to obtain them before the start date.
• Current prescriptive authority in accordance with applicable state requirements.
• Valid driver’s license and reliable transportation for member home visits.
• Ability to meet the organization’s credentialing and privileging requirements.
• Strong clinical assessment and decision-making skills and sound clinical judgment.
• Ability to work independently in a home-based environment.
• Effective communication with members, caregivers, providers, and interdisciplinary teams.
• Strong organizational and time-management skills, attention to documentation and follow-up, and cultural sensitivity.
• Ability to identify and appropriately respond to changes in a member’s clinical condition.
• Ability to manage a mobile caseload, prioritize high-risk clinical needs, coordinate multiple services, and communicate effectively with Case Management and other healthcare professionals.
• Ability to travel regularly each day to member residences within the designated service territory.
• Physical stamina to carry clinical bags and adapt to diverse household settings.
• Ability to comply with applicable federal and state laws and regulations, organizational policies and procedures, professional standards, and health plan requirements.

Nice To Haves

• At least 2 years of experience managing Medicare Advantage, frail elderly, or medically complex populations.
• Experience in primary care, geriatrics, internal medicine, home-based care, transitional care, population health, or care management.
• Experience managing members with multiple chronic conditions and complex healthcare needs.
• Familiarity with post-discharge care, readmission prevention, medication management, and healthcare utilization management.
• Experience collaborating with interdisciplinary care teams.

Responsibilities

• Conduct comprehensive health evaluations of high-risk, complex health plan members in their residences.
• Analyze chronic conditions, symptom progression, and acute clinical changes.
• Evaluate medication regimens for safety, therapeutic intent, and adherence.
• Identify gaps in care, unmet needs, clinical risks, social determinants of health, environmental barriers, and caregiver limitations.
• Determine escalation pathways and the need for diagnostic testing or specialist care.
• Formulate customized clinical recommendations based on member risk profiles.
• Initiate, modify, or adjust treatments within authorized state scope of practice and organizational protocols.
• Order laboratory tests, diagnostic services, and therapeutic interventions as clinically indicated, and track results for timely follow-up.
• Manage acute deterioration through escalation to primary care providers, specialists, or urgent or emergency care facilities.
• Provide evidence-based guidance and individualized education for chronic disease and complex, comorbid conditions.
• Prescribe tailored therapies and medications during in-home consultations.
• Reconcile medication discrepancies, address barriers to adherence, and educate members on complex regimens to prevent adverse drug events.
• Coordinate clinical overrides or alternative treatments with treating physicians and local pharmacies.
• Collaborate with Case Managers and interdisciplinary care team members to support continuity and coordination of care.
• Communicate findings, recommendations, interventions, and follow-up needs to the Case Manager who initiated the referral.
• Coordinate with internal teams and external providers, home health providers, pharmacies, caregivers, and other healthcare professionals as clinically appropriate.
• Provide recommendations for incorporation into the member’s longitudinal care plan and participate in case discussions and interdisciplinary care planning as needed.
• Complete electronic health records immediately after each home visit, documenting findings, risks, care gaps, interventions, orders, education, and the plan of care.
• Document communication and coordination with Case Management, providers, caregivers, and other care team members as applicable.
• Maintain compliance with CMS guidelines, HIPAA, state nursing board requirements, and organizational policies.
• Support early identification of high-risk member needs, timely home-based care, continuity, treatment adherence, appropriate follow-up, and reduction of avoidable emergency room use, hospitalizations, and readmissions.
• Perform clinical functions within education, training, licensure, certification, credentialing, and authorized scope of practice, while maintaining member confidentiality and meeting privacy, security, documentation, quality, and compliance requirements.
• Travel daily within the designated service territory to visit members in their homes and adapt to varied household environments.