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 ot 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 

• Associate or Bachelor of Science in Nursing (BSN preferred) 

• Strong assessment, communication, and care coordination skills 

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