Advanced Practice Registered Nurse

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Full Time Doral, FL, US

2 days ago Requisition

$ To $ Annually

The Advanced Practice Registered Nurse (APRN) – In-Home Clinical Care is responsible for providing comprehensive clinical assessments, interventions, and care coordination for high-risk health plan members in the home setting.

The APRN works collaboratively with the Case Management team and other members of the interdisciplinary care team to address clinical needs, identify gaps in care, improve treatment and medication adherence, and facilitate timely access to appropriate healthcare services. The position primarily supports members who are homebound or bedbound, have recently been hospitalized, demonstrate frequent emergency room utilization, experience barriers to treatment adherence, or are otherwise considered at increased risk for hospitalization, readmission, or avoidable healthcare utilization.

The overall objective of the role is to provide timely clinical care in the member's home, support continuity of care, improve member outcomes, and reduce preventable emergency room visits, hospitalizations, and readmissions.

Remote / Field-Based

• Conduct comprehensive health evaluations for high-risk, complex health plan members within their residences.
• Analyze chronic conditions, symptom progression, and acute clinical changes.
• Evaluate medication regimens to verify safety, therapeutic intent, and adherence.
• Identify gaps in care, unmet systemic needs, and hidden clinical risk factors.
• Uncover social determinants of health (SDOH), environmental barriers, and caregiver limitations affecting health management.
• Determine escalation pathways or the immediate need for advanced diagnostic testing and specialist care.

• Formulate customized clinical recommendations mapped to unique member risk profiles.
• Initiate, modify, or pivot treatments within authorized state scope of practice and organizational protocols.
• Order laboratory tests, diagnostic services, and therapeutic interventions as clinically indicated.
• Track diagnostic results to provide decisive, timely clinical follow-up.
• Manage acute deterioration by executing seamless escalations to PCPs, specialists, or urgent/emergent care facilities.
• Deliver evidence-based guidance to mitigate chronic disease complications.
• Teach individualized strategies for managing complex, comorbid chronic conditions.

• Prescribe tailored therapies and medications during live, in-home consultations.
• Reconcile discrepancies and eliminate barriers to critical medication adherence.
• Educate patients on complex regimens to prevent adverse drug events.
• Coordinate clinical overrides or alternatives directly with treating physicians and local pharmacies.

• Collaborate closely with Case Managers and other members of the interdisciplinary care team to support continuity and coordination of care.
• Communicate clinical findings, recommendations, interventions, and follow-up needs to the Case Manager who initiated the referral.
• Coordinate with the appropriate internal teams to facilitate necessary services and address identified gaps in care.
• Communicate with PCPs, specialists, home health providers, pharmacies, and other healthcare professionals as clinically appropriate.
• Provide recommendations that can be incorporated by Case Management into the member's longitudinal care plan.
• Participate in case discussions and interdisciplinary care planning as needed.

• Author meticulous electronic health records (EHR) immediately following each home visit.
• Document assessment findings, clinical status, identified risks and care gaps, interventions, orders, education provided, and the plan of care.
• Document communication and coordination with Case Management, providers, caregivers, and other members of the care team as applicable.
• Maintain compliance with CMS guidelines, HIPAA, state nursing boards, and organizational policies.

• Current and unrestricted autonomous license as an Advanced Practice Registered Nurse (APRN) in the state in which services are provided.
• Current National Board Certification as a Nurse Practitioner (e.g., AGNP, FNP, or Adult-Gerontology Acute Care) via ANCC or…