Home-Based NP/PA: In-Home Chronic Care Expert

Monogram Health; Savannah (GA); On-site; USD 122,000 - 159,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401k with employer match

20 PTO days + holidays + floating day

Mileage reimbursement

CEU/CME reimbursement

Job summary

Monogram Health is seeking compassionate Advanced Practice Providers (NPs or PAs) to deliver in‑home care to patients with multiple chronic conditions. The role involves working with an integrated care team and delivering care in patients’ homes and via telehealth.

You will participate in a value‑based, patient‑centered care model with a focus on population health, quality outcomes, and ongoing professional development. Travel is required to patient homes.

Qualifications

• Active and unrestricted RN and NP license.
• Board certification (NP: ANCC/AANP | PA: NCCPA).
• Current and unrestricted DEA certificate or eligibility.
• Minimum of two years of direct patient care experience.
• Field-based role requiring travel to patient homes, reliable transportation, valid driver’s license, and auto insurance.
• BLS certification (onboarding).
• Knowledge of HIPAA/OSHA regulations.
• Experience with EHR systems such as Athena, Salesforce or Epic.

Responsibilities

• Provide evidence-based, patient-focused care in the patient’s home to reduce hospitalizations and improve quality of life.
• Perform comprehensive assessments including wellness exams and post-discharge visits.
• Educate patients and caregivers on disease management and preventive care.
• Participate in virtual integrated care team meetings.
• Ensure compliance with state board requirements and best practices through audits and documentation reviews.
• Travel to various care settings as applicable (SNFs, ALFs, hospitals).
• Prescribe medications, order tests, and coordinate with Monogram physician teams.
• Document thoroughly and timely.

Skills

Compassionate care

Education

Nurse Practitioner license

Physician Assistant license

Board certification (NP/PA)

Tools

Athena

Salesforce

Epic

Job description

Monogram Health is seeking compassionate Advanced Practice Providers (NPs or PAs) to deliver in‑home care to patients with multiple chronic conditions. The role involves working with an integrated care team and delivering care in patients’ homes and via telehealth.

You will participate in a value‑based, patient‑centered care model with a focus on population health, quality outcomes, and ongoing professional development. Travel is required to patient homes.