The Nurse Practitioner (NP) – Care@Home at CareMore Health provides high-quality, patient-centered care to members in their homes and community-based settings. This role supports CareMore’s value-based care model by delivering proactive clinical management for medically complex patients, with a focus on improving outcomes, reducing avoidable utilization, and enhancing the member experience.
The Care@Home NP works collaboratively with an integrated interdisciplinary team, including physicians, care managers, social workers, and other clinical partners, to support comprehensive care planning and coordinated transitions of care.
How will you make an impact & Requirements
Key Responsibilities
In-Home Clinical Care & Patient Management
Provide direct in-home care including comprehensive assessments, diagnosis, treatment planning, and ongoing management of acute and chronic conditions.
Deliver preventive care services and health education to promote wellness, early detection, and self-management.
Manage complex and chronically ill populations, including frail, elderly, and homebound members.
Order and interpret diagnostic tests, prescribe medications as appropriate, and coordinate follow-up care based on clinical need.
Identify changes in condition early and intervene promptly to prevent avoidable emergency department visits and hospital admissions.
Transitions of Care & High-Risk Patient Support
Support care transitions following hospital or skilled nursing facility discharges through timely follow-up visits and care coordination.
Collaborate with CareMore physicians and care teams to develop and implement care plans for high-risk members and frequent utilizers.
Coordinate specialty referrals, home health services, DME, community resources, and other supports aligned to patient needs.
Team-Based Collaboration & Care Coordination
Work closely with interdisciplinary teams including physicians, RNs, care managers, social workers, pharmacists, and other support staff.
Participate in case conferences, care planning meetings, and team huddles to align on goals, barriers, and member progress.
Provide clear, empathetic communication and education to members and caregivers to support adherence and engagement in care plans.
Quality, Documentation & Compliance
Maintain timely, accurate documentation in the EMR to support continuity of care, quality outcomes, and regulatory compliance.
