In-Home Advanced Practice NP/PA — Chronic Care Specialist

Monogram Health Professional Services; Acworth (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 and 7 holidays

Job summary

Monogram Health seeks Advanced Practice Providers (NP/PA) to deliver high-quality in-home care to patients with multiple chronic conditions, including diabetes, CKD, and heart failure. You will work within an integrated team, building long-term patient relationships and providing continuity of care at home and via telehealth.

Highlights include 3–4 in-person home visits weekly with 1–2 telehealth visits, no on-call requirements, and 30–90 minute visits tailored to patient needs.

Qualifications

• Licensed and board-certified NP or PA with unrestricted licensure.
• Active RN/NP license or PA license; board certification (NP: ANCC/AANP | PA: NCCPA).
• Experience with EHR systems (Athena, Salesforce, Epic).

Responsibilities

• Provide evidence-based, patient-focused in-home care.
• Perform comprehensive assessments including wellness visits and post-discharge visits.
• Educate patients and caregivers on disease management and medications.
• Coordinate with PCPs, specialists and integrated care team.
• Document accurately and timely, ensuring compliance with regulations.

Skills

Compassionate care

In-home care

Critical thinking

Education

RN/NP license or PA license

Tools

Athena

Salesforce

Epic

Job description

Monogram Health seeks Advanced Practice Providers (NP/PA) to deliver high-quality in-home care to patients with multiple chronic conditions, including diabetes, CKD, and heart failure. You will work within an integrated team, building long-term patient relationships and providing continuity of care at home and via telehealth.

Highlights include 3–4 in-person home visits weekly with 1–2 telehealth visits, no on-call requirements, and 30–90 minute visits tailored to patient needs.