Job Description Summary

‎

Mobile Nurse Practitioner providing in-home patient care, seeing patients with varying levels of acuity.

‎

How will you make an impact & Requirements

‎

With nearly 30 years of experience in providing advanced primary care, CareMore APC delivers exceptional patient experiences. Compassionate clinicians take the time to understand each patient’s unique health needs while also removing barriers to access. Patients trust us to receive the right personalized care where and when they need it – in our care centers, at home or virtually – to improve their health outcomes and quality of life.

Role Description

• Provide in-home patient care across a defined geographic area, seeing patients with varying levels of acuity.

• Primary goal: keep patients clinically stable and reduce avoidable hospitalizations and ER visits.

• Manage chronic medical conditions through ongoing assessment, treatment adjustments, medication management, and patient/family education.

• Address changes in health status promptly through same-day or urgent follow-up visits when needed.

• Identify and close care gaps during visits, including preventive screenings, medication reconciliation, immunizations, safety assessments, and other quality metrics.

• Conduct a variety of visit types, including:

  Post-hospital discharge follow-ups,

  Post-SNF (Skilled Nursing Facility), transitions

  Annual Wellness Visits (AWVs),

  follow-up visits,

  Visits for patients who are homebound or unable to go to clinic.

• Participate in daily clinical rounding with supervising physician to review cases, align on care plans, and ensure high-quality patient management.

• Work as part of a collaborative, interdisciplinary care team, with strong physician oversight and coordination with nursing, social work, care managers, and clinic staff.

• Maintain an empaneled group of homebound and palliative care patients, providing consistent follow-up to ensure their medical, functional, and psychosocial needs are met.

• Lead and document goals-of-care conversations with patients and families to support shared decision-making and ensure care aligns with patient values and preferences.

• Assess appropriateness for hospice and facilitate smooth transitions to hospice care when indicated.

• Collaborate with referring clinicians and clinic-based providers to ensure seamless communication, care alignment, and timely updates.

• Support continuity of care by coordinating community resources, home health services, DME needs, and other supportive services.

• Promote patient and caregiver education to improve understanding of treatment plans and self-management strategies.

Leadership & Supervisory Responsibilities

• Supervise other Nurse Practitioners within the mobile/home-based care team.

• Ensure referral appropriateness, reviewing new patient referrals and triaging them to the correct provider or level of care.

• Monitor team patient distribution, ensuring balanced caseloads and equitable workloads.

• Track team performance metrics, including:

  Cases referred,

  Cases accepted,

  Cases retained/kept, Hospital

  readmissions, ER

  diversion.

• Conduct monthly reviews of performance data, identifying trends, challenges, and opportunities for improvement.

• Provide leadership and support for team growth, fostering clinical excellence, operational efficiency, and high-quality patient care.

• Participate in team huddles, offering insights on patients seen by the team and contributing to care coordination strategies.

Additional Responsibilities

• Support continuity of care by coordinating with community services, home health agencies, DME vendors, and other care partners.

• Ensure seamless communication with referring clinicians and clinic teams to maintain alignment in patient care.

• Promote patient and caregiver education to strengthen self-management and adherence to care plans.

Requirements:

• Requires an MS in Nursing

• Minimum of 5 years of related experience with clinical emphasis for nurse practitioner; or any combination of education and experience, which would provide an equivalent background.

• Current unrestricted RN and NP license

• Satisfactory completion of a Tuberculosis test

Compensation: $139,840K - $209,760K annual salary & bonus eligible

‎