Home Health Nurse Practitioner

Job Summary

Responsibilities

• Provide comprehensive primary care to homebound and high-needs patients attributed to our ACO REACH program.
• Perform physical exams, record detailed medical histories, and develop evidence-based care plans tailored to patients clinical and social needs.
• Diagnose and treat a wide variety of conditions in general practice, with emphasis on chronic disease management and preventive care.
• Collect, record, and maintain accurate patient data in alignment with ACO documentation, coding, and quality reporting requirements.
• Order and interpret diagnostic tests, labs, and imaging studies to inform patient care plans.
• Prescribe and administer appropriate treatments and interventions, including vaccinations and medications.
• Counsel patients and caregivers on disease prevention, nutrition, lifestyle, and adherence to care plans.
• Collaborate with interdisciplinary team members including clinical associates, nurses, and specialists to support whole-person, coordinated care.
• Work closely with acute care, paramedicine, and hospital-at-home partners to proactively manage acute conditions and prevent unnecessary hospital admissions.
• Manage pressure ulcers, wounds, Foley and suprapubic catheters, and provide phlebotomy/IV access as needed.
• Participate in regular case conferences and patient panel reviews with the ACO team (typically every 3-4 weeks onsite in the Bronx).
• Provide timely, accurate charting and coding that reflects clinical care and ACO program standards.
• Share in after-hours coverage of the ACO emergency hotline on a rotating schedule.
• Ability to work closely and train under PCP's and other specialists to gain additional experience and knowledge.
• Collaboration with dedicated care managers and a Health Home program to assist patients with Social Determinants of Health and to provide social support.

Qualifications

• Graduate of an accredited NP or PA program.
• Current New York State license and National Board Certification.
• Active DEA license.
• Minimum 3 years of clinical experience, preferably including home-based primary care, geriatrics, or complex chronic care management.
• Experience with value-based care models (e.g., ACOs, risk-bearing entities, or Medicare programs) strongly preferred.
• Familiarity with care coordination and quality reporting in ACO or similar programs.
• EMR/EHR proficiency required.
• Bilingual (Spanish) strongly preferred.
• Demonstrated ability to work independently in the home setting while collaborating with a multidisciplinary team.