In-Home NP/PA: Chronic Care Innovator

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

Benefits offered by this job

Mileage reimbursement

CEU/CME reimbursement

$5,000 anniversary bonus

Bonus opportunities up to 15%

Job summary

Monogram Health is seeking compassionate Advanced Practice Providers (NP/PA) to deliver high-quality in-home care to patients with multiple chronic conditions, including diabetes, hypertension, CKD, heart failure, COPD, and depression.

This role involves 3–4 home visits per week plus 1–2 telehealth visits, with no on-call or weekend duties. Visit lengths range from 30 to 90 minutes to fit patient needs.

Qualifications

• Active and unrestricted RN and NP license, or Physician Assistant license.
• Board certification (NP: ANCC/AANP | PA: NCCPA).
• Current and unrestricted DEA certificate, or eligibility to obtain.
• Minimum of two (2) 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 (supported during onboarding).
• Demonstrated initiative and independent, critical thinking, and decision-making skills.
• Knowledge of and compliance with federal/state regulations (HIPAA, OSHA).
• Prior experience with EHR systems (e.g. Athena, Salesforce, Epic).
• Previous experience conducting annual wellness or comprehensive visits preferred.
• Background in managed care, population health, or value-based care preferred.

Responsibilities

• Provide evidence-based, patient-focused care in the patient’s home.
• Perform comprehensive assessments including initial evaluations, wellness exams, and follow-ups.
• Educate patients and caregivers on disease management and preventive care.
• Participate in recurring virtual care team meetings.
• Engage in QA activities and documentation reviews for compliance.
• May practice in SNFs, ALFs, hospitals, and other settings as applicable.
• Perform point-of-care testing and collaborate with the patient’s Monogram physician.
• Coordinate care with PCPs, specialists, and ancillary services.
• Complete documentation accurately and in a timely manner.

Skills

Patient care

Home visits

Team collaboration

Documentation

EHR experience

Education

RN/NP or PA license

Tools

Athena

Salesforce

Epic

Job description

Monogram Health is seeking compassionate Advanced Practice Providers (NP/PA) to deliver high-quality in-home care to patients with multiple chronic conditions, including diabetes, hypertension, CKD, heart failure, COPD, and depression.

This role involves 3–4 home visits per week plus 1–2 telehealth visits, with no on-call or weekend duties. Visit lengths range from 30 to 90 minutes to fit patient needs.