Position Summary

The Director of Advanced Home Care is a clinical leader responsible for developing and expanding innovative home-based care programs that improve care transitions, reduce avoidable hospital utilization, and enhance patient outcomes. This hybrid role combines limited direct patient care with significant responsibility for strategic planning, business development, provider engagement, and program implementation.

Working closely with hospitals, health systems, physician practices, Accountable Care Organizations (ACOs), Medicare Advantage plans, and community providers, the Nurse Practitioner will develop partnerships that create seamless transitions for patients with serious illness and complex medical needs. This role is ideal for a highly experienced Nurse Practitioner who enjoys building programs, developing relationships, and driving healthcare transformation while maintaining clinical credibility through direct patient care.

Essential Functions

Strategic Development

• Lead the development and expansion of home-based transitional care, palliative care, and advanced primary care programs.
• Identify opportunities to improve post-acute care coordination and reduce preventable emergency department visits and hospital readmissions.
• Develop strategic partnerships with hospitals, health systems, physician groups, skilled nursing facilities, home health agencies, and community organizations.
• Serve as the organization's clinical liaison with discharge planners, case managers, care coordinators, physicians, and executive leadership.
• Design referral pathways and standardized workflows that support timely in-home follow-up after hospitalization.
• Assist with implementation of value-based care strategies, including ACO REACH, GUIDE, Medicare Advantage, and other risk-based programs.

Clinical Leadership

• Analyze utilization, quality, and performance metrics to identify opportunities for program improvement.
• May provide clinical consultation to interdisciplinary teams caring for medically complex patients.
• Support evidence-based care delivery focused on serious illness management, symptom management, advance care planning, and chronic disease management.
• Assist in developing clinical protocols, care pathways, and best practices.
• Mentor providers and participate in ongoing clinical education initiatives.

Direct Patient Care

• Conduct in-home evaluations for patients transitioning from hospitals, rehabilitation facilities, and skilled nursing facilities.
• Perform comprehensive medical assessments, medication reconciliation, and transitional care management visits.
• Provide palliative care consultations, serious illness management, and advanced primary care services for high-risk patients.
• Facilitate goals-of-care discussions and advance care planning.
• Develop individualized care plans in collaboration with physicians, nurses, social workers, and community partners.
• Coordinate care across multiple healthcare settings to ensure continuity of care.

Qualifications

Knowledge and Critical Skills

• Demonstrated ability to build relationships with physicians, hospitals, and healthcare organizations.
• Strong communication, presentation, and organizational skills.
• Knowledge of value-based care models, including Medicare Shared Savings, ACO REACH, GUIDE, and Medicare Advantage.

Preferred Experience:

• Experience in home-based primary care or palliative care.
• Experience developing new healthcare programs or service lines.
• Experience with quality improvement and population health initiatives.

Experience

• Minimum five years of advanced practice experience.
• Clinical experience in palliative care, geriatrics, internal medicine, family medicine, hospital medicine, home-based care, or transitional care.

License / Certification

• Current Florida APRN license with national board certification (FNP, AGPCNP, or AGACNP).
• DEA registration and prescriptive authority.
• Valid driver's license and ability to travel throughout the service area.
• Certification in Hospice and Palliative Care (ACHPN) or equivalent, preferred.

Education

• Graduate, advanced education with Master's Degree

Other Requirements

• Must have medical clearance for communicable diseases before direct patient contact.
• Current immunizations including but not limited to TB, Hepatitis, and Flu.

The knowledge, skills and abilities listed above are typically acquired through the levels of education and experience listed. However, any equivalent combination of education and/or experience, which provide an applicant with the listed knowledge, skills, and abilities to perform the essential duties and responsibilities of the job, is acceptable.

This description is intended to describe the general nature and level of work performed by employees assigned to this role. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or working conditions required of employees in this position. The organization reserves the right to modify or amend the duties of the position or to require that additional tasks be performed as organizational needs change. This description does not constitute a contract of employment, and employment with the organization is at-will, meaning either the employee or the organization may terminate the relationship at any time, with or without cause or notice.