Home-Based Nurse Practitioner — Community Care & Transitions

AbsoluteCare; Greenbelt (MD); On-site; USD 110,000 - 160,000; Full time

Job summary

AbsoluteCare in Maryland is seeking a Community-based Clinician to provide primary and urgent care in the home, with a strong focus on transitions of care after hospital discharge. You will collaborate with the patient’s PCP, care manager, and the Integrated Care Team to coordinate visits and resources, ensuring timely follow-up and smooth handoffs.

You will manage a small panel of homebound members, address acute issues in the home or clinic, educate patients on chronic disease self-management

Qualifications

• This is a Community Based position; willing to do home visits.
• ACLS certified.
• Ability to meet deadlines and manage multiple priorities.
• Experience using EMR and data reporting.
• Patient-centered focus and problem-solving skills.
• Familiar with care transitions and reducing readmissions.

Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges.
• Manage a small panel of homebound members who require primary care.
• Resolve acute issues in the home and clinic or direct patients to the most effective solutions.
• Coordinate with PCP, care manager, and social workers to define visit goals.
• Communicate important post-visit follow-up information to the core clinical team.
• Collaborate with Integrated Care Team (ICT) members for problem solving and coordination of care.
• Identify referrals to specialty programs during instability or crisis.
• Implement transitional care protocols during warm handoffs between internal and external care providers.
• Educate and coach for medication adherence and chronic disease self-management.
• Monitor members at risk of loss to care and intervene to prevent loss.

Skills

Care coordination

Patient-centered care

Time management

Problem-solving

Adaptability

Education

Certified Registered Nurse Practitioner - Adult Medicine

ACLS certified

Tools

Electronic Medical Records (EMR)

Microsoft Office

Job description

AbsoluteCare in Maryland is seeking a Community-based Clinician to provide primary and urgent care in the home, with a strong focus on transitions of care after hospital discharge. You will collaborate with the patient’s PCP, care manager, and the Integrated Care Team to coordinate visits and resources, ensuring timely follow-up and smooth handoffs.

You will manage a small panel of homebound members, address acute issues in the home or clinic, educate patients on chronic disease self-management