Registered Nurse (RN) - ACO House Call Services

Registered Nurse (RN) – ACO House Call Services Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state's most vulnerable and underserved residents. Founded in 1999, we've grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women's health to endocrinology and psychiatry. We also provide nursing home support, care management services, and in-home medical services through our House CallsDivision, Intention Health Care and Facilitate smooth transitions between care settings including telehealth, in-person medical visits, and home care through Intention Health Care. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it. We're looking for talented, motivated individuals to join our growing team. Whether you're a medical provider, administrator, or operations professional, there's a career here for you. Join us in making a real difference in the health of our community. Job Summary Position Title: Registered Nurse (RN) – ACO House Call Services Department: Intention Health - ACO Reach Position Summary: 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. Responsibilities Clinical Care & In-Home Assessments 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) Care Coordination & Care Management 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 Medication Management 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 ACO / Value Based Care Support 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 Documentation & Communication 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 Patient & Caregiver Education 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 Qualifications Qualifications: Required: Active Registered Nurse (RN) license in the state of practice Bachelor of Science in Nursing Strong assessment, communication, and care coordination skills Minimum of one year of adult inpatient hospital nursing experience or one year of experience practicing as a home health registered nurse Preferred: 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 Skills & Competencies: 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 Work Environment: Community based role with regular in-home patient visits Combination of fieldwork and remote documentation Schedule may include weekday visits with occasional flexibility based on patient needs Equal Opportunity Employer Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population