Mobile Registered Nurse - I-SNP

Mobile Registered Nurse– I‑SNP Company Information Company: Avail Health Medical Practice of Florida, P.A. Reports To: VP of Care Delivery, Katie Korte Location: This position is a hybrid, primarily mobile role and must be located within the geographic region of Reisterstown, Maryland or within a reasonable commuting distance. About Avail Healthcare Avail Healthcare is a Nurse Practitioner–founded organization dedicated to removing barriers to care, access, and meaningful clinical work for Medicare-age individuals. We combine thoughtful technology, strong operational infrastructure, and deep respect for the patient–provider relationship to enable nurse‑led virtual and mobile care models. As a fast‑growing organization, we are building durable clinical infrastructure to support innovative care programs across multiple states, with a focus on improving outcomes for complex and underserved senior populations. Position Summary The Mobile Registered Nurse (RN) delivers high‑quality, patient‑centered nursing care to Institutional Special Needs Plan (I‑SNP) members residing in long‑term care skilled nursing facilities (SNFs). This role focuses on proactive clinical support, early identification of condition changes, care coordination, and patient advocacy for a frail, medically complex population. This is a full‑time W‑2 position with a defined end date of December 2026. This role is aligned to current program needs, with the potential for extension based on business requirements and performance. The RN partners closely with Nurse Practitioners (NPs), Care Coordinators (CCs), facility staff, and the broader interdisciplinary team to improve clinical outcomes, reduce avoidable hospitalizations, and enhance quality of life while supporting effective utilization of healthcare resources. This is a highly collaborative, patient‑facing role that requires strong clinical judgment, effective communication, and the ability to translate clinical findings into actionable care plans. The RN partners closely with Avail Health operations to support efficient scheduling, timely and accurate documentation, and overall program execution, including alignment with Medicare Advantage and I‑SNP requirements. In addition, the RN conducts Health Risk Assessments in collaboration with members and, when appropriate, their authorized representatives, identify clinical and social risk factors. Based on these assessments, the RN develops individualized care plans—including problems, goals, and interventions—that inform care coordination efforts and support the interdisciplinary team responsible for ongoing member care. Success in this role requires comfort working independently in the field, adaptability in a dynamic environment, and a proactive approach to continuous improvement and program development. Location & Work Environment This is a primary mobile, field‑based role requiring residence within Maryland, with regional coverage for assigned areas. Candidates who are centrally located within the coverage area and able to support efficient daily travel are strongly preferred. Standard hours are Monday through Friday, 8:00 AM – 5:00 PM EST. Remote work requires a reliable high‑speed internet connection and a dedicated, HIPAA‑compliant workspace to ensure the security and confidentiality of patient information and organizational communications. Key Responsibilities Provide in‑person nursing assessments for I‑SNP members, including routine wellness checks, post‑acute follow‑up, and condition‑specific evaluations. Conduct comprehensive Health Risk Assessments (HRAs) to identify clinical, functional, behavioral, and social determinants of health needs. Assist in the development, implementation, and ongoing updating of individualized care plans in collaboration with NPs and the interdisciplinary care team. Monitor and document changes in patient condition, identifying early signs of clinical deterioration and escalating appropriately. Support Nurse Practitioners in care delivery by gathering clinical data, performing focused assessments, and facilitating timely interventions. Coordinate care across interdisciplinary teams, including facility staff, specialists, rehabilitation services, and family members. Assist with transitions of care, including admissions, readmissions, and discharges, ensuring continuity and accuracy of care plans. Perform medication reconciliation and support medication adherence through patient and caregiver education. Provide patient, family, and caregiver education on disease management, treatment plans, and goals of care. Support chronic disease management and preventive care initiatives for high‑risk populations. Participate in interdisciplinary care plan meetings and contribute nursing insights to care planning. Facilitate communication between patients, families, facility staff, and providers to ensure aligned, coordinated care. Assist in reducing avoidable hospitalizations through proactive monitoring and timely intervention. Document all patient interactions accurately and in a timely manner within the electronic medical record (EMR). Ensure compliance with I‑SNP program requirements, regulatory standards, and organizational protocols. What Success Looks Like Early Risk Identification: Consistently identifies subtle clinical changes and escalates appropriately, preventing avoidable deterioration. Strong Clinical Partnership: Acts as a trusted extension of the NP, enabling efficient, high‑quality care delivery. Seamless Care Coordination: Ensures patients, families, and care teams are aligned, with minimal gaps in communication or execution. Effective Transitions: Smoothly manages transitions of care with clear follow‑through and minimal readmissions. High‑Quality Documentation: Delivers timely, accurate, and actionable documentation that supports clinical and operational workflows. Patient‑Centered Impact: Builds trust with patients and caregivers, improving engagement, adherence, and overall experience. Operational Reliability: Manages schedule and responsibilities independently while maintaining strong coordination with the broader team. Program Contribution: Identifies workflow gaps and contributes to continuous improvement of the I‑SNP care model. Qualifications Associate Degree in Nursing (ADN) from an accredited program required; Bachelor of Science in Nursing (BSN) preferred. Current, unrestricted Registered Nurse (RN) license in Maryland, maintained in good standing and in compliance with all applicable state regulations throughout employment. Minimum of 1–3 years of clinical experience required, preferably in geriatrics, long‑term care, skilled nursing facilities (SNFs), home health, or other post‑acute care settings. Demonstrated experience working with medically complex, high‑risk, or frail elderly populations. Strong clinical assessment skills with the ability to identify subtle changes in condition and elevate appropriately. Excellent communication and interpersonal skills, with the ability to effectively engage patients, families, facility staff, and interdisciplinary team members. Proficiency with electronic health records (EHRs) and comfort working in technology‑enabled care models. Strong organizational and time‑management skills, with the ability to manage a mobile schedule across multiple facilities. Ability to work independently in a field‑based setting while maintaining close coordination with a remote interdisciplinary team. Residence in Maryland with ability to travel within the assigned regions as needed. Authorization to work in the United States. Preferred Qualifications Experience in value‑based care models, including Medicare Advantage and/or I‑SNP populations. Familiarity with care transitions, chronic disease management, and post‑acute care workflows. Exposure to risk stratification, quality metrics, and HEDIS/STARS measures. Experience supporting interdisciplinary care planning and coordination across multiple care settings. Prior experience in mobile care delivery or community‑based care models. Compensation & Benefits Base Salary: Base salary range of $90,000 – $110,000, depending on experience, scope, and qualifications. Retirement: 401(k) retirement plan with a 2% employer match, subject to plan terms and eligibility requirements. Performance Bonus: Employees may be eligible for a discretionary performance bonus based on individual performance, role‑specific metrics, and overall company performance. Bonus structure and targets vary by role and are not guaranteed. Employees must be actively employed on the payout date to receive any bonus. Annual Compensation Review: Compensation is reviewed annually and may be adjusted based on performance, market data, and organizational factors. Adjustments are not guaranteed. Mileage Reimbursement: $0.725 per mile for travel exceeding 30 miles per day, up to $200 per day. Benefits Package: Comprehensive benefits include medical, dental, and vision coverage. The company offers a Direct Primary Care (DPC) model paired with a high‑deductible health plan and covers 100% of employee medical premiums, with dependent coverage subsidized. Additional benefits include company‑paid life and disability insurance, and employer contributions to a Health Savings Account (HSA). Paid Time Off: Employees accrue 15 days of paid time off annually, increasing with tenure. PTO accrues per pay period. Holidays: 8 paid company holidays plus 1 floating holiday annually. Support & Resources Avail Health provides all necessary devices for clinical and technology‑related activities. Professional liability and malpractice insurance coverage ($1M/$3M) provided. #J-18808-Ljbffr Vail Health