Registered Nurse; RN – ACO House Call Services

Company Overview

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

Registered Nurse (RN) - ACO House Call Services

Intention health - ACO Reach

The Registered Nurse (RN) for ACO House Call Services is a critical member of the care team. You are expected to operate independently, identifying and serving patients’ needs, using your best judgment to help implement their care plan, or to elevate if and when you feel changes need to be made. In some cases, you will come to know the patient and their health status better than their PCP.

Serving our highly vulnerable, highly complex population, you will complete independent as well as tele-assisted medical visits, conduct in home clinical and risk assessments, facilitate care coordination, and educate patients and their families on their diagnoses, risks, and recommendations for healthier living. This role supports value-based care initiatives by improving care transitions, reducing avoidable utilization, closing care gaps, and enhancing patient outcomes through proactive, patient-centered home-based services.

• Conduct comprehensive in-home nursing assessments, including physical, psychosocial, functional, and environmental evaluations
• Identify acute and chronic health issues, medication concerns, and safety risks in the home
• Perform vital signs, health screenings, and condition specific assessments per protocol
• Provide disease specific education (e.g., CHF, COPD, diabetes, HTN, Dementia, Fall-Risk)

• Develop, implement, and update individualized care plans in collaboration with interdisciplinary teams
• Coordinate care across primary care, specialists, behavioral health, home health, SNFs, and community resources
• Support care transitions following hospitalizations, ED visits, and SNF discharges
• Address social drivers of health (SDOH) and connect patients to appropriate community services

• Perform medication reconciliation during home visits
• Identify medication discrepancies, adherence issues, side effects, and potential interactions
• Educate patients and caregivers on medication purpose, dosing, and safety
• Communicate medication concerns to PCPs, pharmacists, and care teams

• Support ACO quality measures, utilization reduction, and risk-based outcomes
• Assist with closing quality care gaps
• Document accurately to support clinical quality, risk adjustment, and compliance initiatives
• Participate in addressing high utilizers and preventable readmissions

• Document all visits and interventions accurately and timely in the EHR
• Communicate findings and recommendations to PCPs and interdisciplinary care teams
• Participate in case conferences, huddles, and quality improvement initiatives

• Educate patients and caregivers on disease management, symptom monitoring, and when to seek care
• Promote self-management, adherence to care plans, and preventative care
• Support advance care planning and goals of care discussions as appropriate

• Active Registered Nurse (RN) license in the state of practice
• Bachelor of Science in Nursing
• Strong assessment, communication, and care…