ACO Housecalls Nurse Practitioner (NP) or Physician Assistant (PA)

Quick Facts

• Role: ACO Housecalls Nurse Practitioner (NP) or Physician Assistant (PA)

• Setting: In-home primary care for homebound, high-needs patients

Description

Join the ACO REACH High Needs housecalls team to deliver mission-driven primary care for complex, high-risk patients in New York through evidence-based, value-based care. You’ll assess patients, build personalized treatment plans, manage chronic and preventive care, and help prevent avoidable hospitalizations by coordinating with an interdisciplinary team. You’ll also maintain ACO documentation, coding, and quality reporting, participate in case conferences, and rotate on after-hours emergency hotline coverage.

Responsibilities

• Provide comprehensive primary care to homebound and high-needs patients attributed to the ACO REACH program

• Perform physical exams and record detailed medical histories

• Develop evidence-based care plans tailored to clinical and social needs

• Diagnose and treat conditions in general practice, with emphasis on chronic disease management and preventive care

• Collect, record, and maintain accurate patient data aligned with ACO documentation, coding, and quality reporting requirements

• Order and interpret diagnostic tests, labs, and imaging studies

• Prescribe and administer treatments and interventions, including vaccinations and medications

• Counsel patients and caregivers on prevention, nutrition, lifestyle, and adherence

• Collaborate with clinical associates, nurses, and specialists to deliver whole-person coordinated care

• Coordinate with acute care, paramedicine, and hospital-at-home partners to proactively manage acute conditions and prevent unnecessary hospital admissions

• Manage pressure ulcers, wounds, Foley and suprapubic catheters; provide phlebotomy/IV access as needed

• Participate in regular case conferences and patient panel reviews with the ACO team (onsite in the Bronx every ~3–4 weeks)

• Provide timely, accurate charting and coding reflecting clinical care and ACO program standards

• Share in after-hours coverage of the ACO emergency hotline on a rotating schedule

• Work closely with PCPs and other specialists to gain additional experience and knowledge

• Collaborate with care managers and a Health Home program to assist patients with Social Determinants of Health and social support

Requirements

• Graduate of an accredited NP or PA program

• Current New York State license and National Board Certification

• Active DEA license

• Minimum 3 years of clinical experience (preferably including home-based primary care, geriatrics, or complex chronic care management)

• Experience with value-based care models (e.g., ACOs, risk-bearing entities, or Medicare programs) strongly preferred

• Familiarity with care coordination and quality reporting in ACO or similar programs

• EMR/EHR proficiency required

• Bilingual (Spanish) strongly preferred

• Ability to work independently in the home setting while collaborating with a multidisciplinary team