Job Summary
Join our ACO REACH High Needs team at Essen House Calls as a Nurse Practitioner or Physician Assistant and play a pivotal role in transforming how healthcare is delivered to some of the most complex, high-risk patients in New York. This is more than primary care it s mission-driven, in-home care that combines clinical excellence with innovation in value-based care. You ll work at the forefront of care delivery, developing personalized treatment plans, preventing avoidable hospitalizations, and collaborating with an interdisciplinary team to improve health outcomes and equity. As part of our ACO, you ll not only care for patients but also help shape a new model of healthcare designed around quality, compassion, and impact.
Responsibilities
Provide comprehensive primary care to homebound and high-needs patients attributed to our ACO REACH program.
Perform physical exams, record detailed medical histories, and develop evidence-based care plans tailored to patients clinical and social needs.
Diagnose and treat a wide variety of conditions in general practice, with emphasis on chronic disease management and preventive care.
Collect, record, and maintain accurate patient data in alignment with ACO documentation, coding, and quality reporting requirements.
Order and interpret diagnostic tests, labs, and imaging studies to inform patient care plans.
Prescribe and administer appropriate treatments and interventions, including vaccinations and medications.
Counsel patients and caregivers on disease prevention, nutrition, lifestyle, and adherence to care plans.
Collaborate with interdisciplinary team members including clinical associates, nurses, and specialists to support whole-person, coordinated care.
Work closely 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, and provide phlebotomy/IV access as needed.
Participate in regular case conferences and patient panel reviews with the ACO team (typically every 3 4 weeks onsite in the Bronx).
Provide timely, accurate charting and coding that reflects clinical care and ACO program standards.
Share in after-hours coverage of the ACO emergency hotline on a rotating schedule.
Ability to work closely and train under PCP's and other specialists to gain additional experience and knowledge
Collaboration with dedicated care managers and a Health Home program to assit patients with Social Determinants of Health and to provide social support.
Qualifications
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.
Demonstrated ability to work independently in the home setting while collaborating with a multidisciplinary team.
