Registered Nurse

Why Join Grace at Home?

Grace at Home is a provider‑led, community‑based health and care partner dedicated to improving the health and well‑being of those who need care the most, with a deep commitment to high‑needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in‑home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes.

By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

The RN reports to the Clinical Manager or designee, with accountability for providing strategy, judgment, organization, and evidence‑based analysis to influence decisions, and directly to meet Grace at Home’s requirements. They should embody Grace at Home’s core values, including Trusted, Empathetic, Committed, Humble, Creative and Community‑Minded. At Grace at Home, we don’t have patients or customers – we have Family Members.

Grace at Home model is designed for member engagement of the high‑risk population with an emphasis on event‑driven care management leveraging care pathways and evidence‑based guidelines tailored to black and brown populations. Care Management includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing Nursing Care Plans, managing the patient care transition process, assisting patients throughout care episodes, coordinating, and facilitating care for patients with complex, chronic medical and mental health conditions, providing disease education, and promoting evidence‑based healthcare services.

The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for patients/families struggling with chronic disease management. It is critical that care management be done in conjunction and always with the Caregiver, including their and the member’s signoff. Conducting Caregiver assessments are also part of the Care Management process.

In this role, you’ll collaborate closely with a multi‑disciplinary clinical team to deliver high‑quality, personalized care in both a home‑based and telehealth setting. The ideal candidate is committed to providing longitudinal care to build meaningful patient relationships, improving patient outcomes, and eager to make a meaningful impact in underserved communities.

• The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for Grace at Home’s members/families struggling with chronic disease management.
• Works with member and care team to conduct appropriate assessments that result in a nursing care plan prioritized by the patient and caregivers.
• Conducts in‑home or tele‑health assessments, as directed by the model and leadership.
• Track nursing care plan outcomes, interventions, and continue to reassess the patient's needs as appropriate.
• Utilizes care pathway templates by condition with risk levels and member actions by event type.
• Deploys Remote Patient Monitoring and Patient Self Reporting for High‑Risk Chronic Conditions.
• Conducts transition of care visits both virtually and in‑home to ensure smooth transition from an acute care setting to home.
• Provide care coordination for Grace at Home’s Family Members including patient navigation, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.
• Engage members in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow‑up appointments and refer patients to the appropriate community‑based organizations or other programs.
• Follow evidence‑based guidelines to facilitate closure of gaps in care and encourage and use of in‑network services if appropriate and determine when in‑home…