Job Description Summary
The Mobile Nurse Practitioner (NP) provides high-quality, patient-centered primary and palliative care services through home visits to high-risk, homebound, and empaneled palliative care patients. This role focuses on transitional care management (TOC), chronic disease management, acute condition evaluation, closing care gaps, and proactive interventions to reduce hospitalizations and emergency department utilization. The NP collaborates closely with a supervising physician and interdisciplinary care team to ensure continuity of care, stabilize complex patients, and improve overall health outcomes.
How will you make an impact & Requirements
Clinical Care Delivery
Conduct in-home visits for high-risk, homebound, and empaneled palliative care patients.
Perform comprehensive assessments, including physical exams, medication reconciliation, and risk stratification.
Manage acute and chronic medical conditions.
Develop, implement, and adjust individualized care plans in collaboration with the supervising physician.
Provide symptom management and supportive care for palliative patients.
Order, interpret, and follow up on diagnostic tests and labs.
Prescribe medications in accordance with state regulations and collaborative agreement.
Transitional & High-Risk Care
Perform Transitional Care Management (TOC) visits following hospital or skilled nursing facility discharge.
Evaluate and intervene with UTR (Unable to Reach) or disengaged high-risk patients as needed.
Address clinical instability early to prevent emergency department visits and hospital readmissions.
Provide urgent same-day or next-day evaluations when appropriate.
Chronic Disease Management
Manage complex chronic conditions (e.g., CHF, COPD, diabetes, CKD, hypertension).
Optimize medication regimens and ensure adherence.
Monitor disease progression and adjust care plans proactively.
Care Gap Closure & Quality Initiatives
Identify and close preventive and quality care gaps (e.g., screenings, vaccinations, medication monitoring).
Ensure compliance with value-based care metrics and quality benchmarks.
Document thoroughly and accurately in the electronic health record (EHR).
Care Coordination
Collaborate with supervising physician, nurses, social workers, care coordinators, and specialists.
Facilitate referrals to community resources, hospice, home health, and specialty care.
Communicate effectively with patients, families, caregivers, and interdisciplinary teams.
Participate in case reviews and team meetings.
The Mobile NP must demonstrate advanced clinical judgment, strong assessment and diagnostic skills, and sound decision-making capabilities. The ability to work independently in a community-based setting while maintaining close collaboration with a supervising physician is essential. Candidates must be proficient in electronic health record (EHR) documentation and committed to quality improvement and value-based care principles.
Core competencies include compassionate, patient-centered care delivery; strong communication and interdisciplinary collaboration skills; effective time management; adaptability in dynamic home environments; and a proactive commitment to reducing avoidable hospitalizations and improving patient stability.
This is a community-based role requiring regular travel to patient homes. Candidates must possess a valid driver’s license, reliable transportation, and the ability to perform physical assessments, transport and carry medical equipment, and adapt to varied home settings. Flexible scheduling is required to meet patient care needs.
Compensation:
$119,313.00to
$178,968.00