Advanced Practice Registered Nurse

Position Summary

The Advanced Practice Registered Nurse (APRN) – In-Home Clinical Care is responsible for providing comprehensive clinical assessments, interventions, and care coordination for high-risk health plan members in the home setting.

The APRN works collaboratively with the Case Management team and other members of the interdisciplinary care team to address clinical needs, identify gaps in care, improve treatment and medication adherence, and facilitate timely access to appropriate healthcare services. The position primarily supports members who are homebound or bedbound, have recently been hospitalized, demonstrate frequent emergency room utilization, experience barriers to treatment adherence, or are otherwise considered at increased risk for hospitalization, readmission, or avoidable healthcare utilization.

The overall objective of the role is to provide timely clinical care in the member's home, support continuity of care, improve member outcomes, and reduce preventable emergency room visits, hospitalizations, and readmissions.

Location: Remote / Field-Based

Essential Duties and Responsibilities

In-Home Clinical Assessment

• Conduct comprehensive health evaluations for high-risk, complex health plan members within their residences.
• Analyze chronic conditions, symptom progression, and acute clinical changes.
• Evaluate medication regimens to verify safety, therapeutic intent, and adherence.
• Identify gaps in care, unmet systemic needs, and hidden clinical risk factors.
• Uncover social determinants of health (SDOH), environmental barriers, and caregiver limitations affecting health management.
• Determine escalation pathways or the immediate need for advanced diagnostic testing and specialist care.

Clinical Intervention and Management

• Formulate customized clinical recommendations mapped to unique member risk profiles.
• Initiate, modify, or pivot treatments within authorized state scope of practice and organizational protocols.
• Order laboratory tests, diagnostic services, and therapeutic interventions as clinically indicated.
• Track diagnostic results to provide decisive, timely clinical follow-up.
• Manage acute deterioration by executing seamless escalations to PCPs, specialists, or urgent/emergent care facilities.
• Deliver evidence-based guidance to mitigate chronic disease complications.
• Teach individualized strategies for managing complex, comorbid chronic conditions.

Medication and Treatment Management

• Prescribe tailored therapies and medications during live, in-home consultations.
• Reconcile discrepancies and eliminate barriers to critical medication adherence.
• Educate patients on complex regimens to prevent adverse drug events.
• Coordinate clinical overrides or alternatives directly with treating physicians and local pharmacies.

Care Coordination and Collaboration

• Collaborate closely with Case Managers and other members of the interdisciplinary care team to support continuity and coordination of care.
• Communicate clinical findings, recommendations, interventions, and follow-up needs to the Case Manager who initiated the referral.
• Coordinate with the appropriate internal teams to facilitate necessary services and address identified gaps in care.
• Communicate with PCPs, specialists, home health providers, pharmacies, and other healthcare professionals as clinically appropriate.
• Provide recommendations that can be incorporated by Case Management into the member's longitudinal care plan.
• Participate in case discussions and interdisciplinary care planning as needed.

Documentation

• Author meticulous electronic health records (EHR) immediately following each home visit.
• Document assessment findings, clinical status, identified risks and care gaps, interventions, orders, education provided, and the plan of care.
• Document communication and coordination with Case Management, providers, caregivers, and other members of the care team as applicable.
• Maintain compliance with CMS guidelines, HIPAA, state nursing boards, and organizational policies.

Qualifications

• Current and unrestricted autonomous license as an Advanced Practice Registered Nurse (APRN) in the state in which services are provided.
• Current National Board Certification as a Nurse Practitioner (e.g., AGNP, FNP, or Adult-Gerontology Acute Care) via 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 eligible to obtain before 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 all credentialing and privileging requirements established by the organization.

Preferred Experience

• Geriatric or Complex Care: 2+ years 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 working collaboratively with interdisciplinary care teams.

Knowledge, Skills, and Competencies

The successful candidate should demonstrate strong clinical assessment and decision-making skills, the ability to work independently in a home-based environment, and effective communication with members, caregivers, providers, and interdisciplinary teams. The APRN must demonstrate sound clinical judgment, strong organizational and time-management skills, attention to documentation and follow-up, cultural sensitivity, and the ability to identify and respond appropriately to changes in a member's clinical condition. The position also requires the ability to manage a mobile caseload, prioritize high-risk clinical needs, coordinate multiple services, and maintain effective communication with Case Management and other healthcare professionals.

Travel Requirements

• Field-Based Travel: Requires regular, daily local travel to member residences within the designated service territory.
• Caseload Nature: Exposure to varied home environments; requires physical stamina to carry clinical bags and adapt to diverse household settings

Program Objectives

The APRN supports the organization's In-House APRN Home Visit Program by helping to:

• Identify and address the needs of high-risk members early.
• Provide timely clinical assessment and intervention in the home.
• Improve coordination and continuity of care.
• Address gaps in care and barriers to treatment.
• Support medication and treatment adherence.
• Monitor clinical outcomes and facilitate appropriate follow-up.
• Reduce avoidable emergency room utilization, hospitalizations, and readmissions.
• Promote safe, appropriate, and member-centered care in the least restrictive setting clinically appropriate.

Scope and Compliance

The APRN performs all clinical functions within the individual's education, training, licensure, certification, credentialing, and authorized scope of practice. All services must be provided in accordance with applicable federal and state laws and regulations, organizational policies and procedures, professional standards of practice, and health plan requirements.

The APRN is expected to maintain member confidentiality and comply with HIPAA and all applicable privacy, security, documentation, quality, and compliance requirements