Nurse Practitioner (Care Delivery — CCM, RPM, and BHI Program) - New York Licensed

Who We Are
Horizon Psychology Services is committed to providing compassionate, evidence-based mental health care, specializing in the unique needs of older adults. We support our clients as they navigate aging, health challenges, and major life transitions. At Horizon, we deliver high-touch, coordinated care for patients with chronic conditions and complex needs through Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and Behavioral Health Integration (BHI). Learn more about us here:

Why Join Our Mission?
We foster a collaborative, inclusive, and supportive environment for both our clients and clinicians. We believe in continuous learning, professional growth, and making a meaningful impact on the older adult and geriatric community across New York City.

Ready to Make an Impact?
We are seeking a New York State Licensed Nurse Practitioner (NP) to join our remote team in New York City. This role is ideal for someone who excels at relationship-based care, proactive follow-up, and tight coordination across patients, families/caregivers, specialists, and internal care team members. We’re looking for a clinician who is passionate about working with older adults aged 55 and older, helping them manage their health-related concerns.

As a Nurse Practitioner on our CCM/RPM/BHI program, you will provide direct medical care and serve as a clinical quarterback for ongoing care coordination. You’ll manage chronic conditions, respond to RPM trends, close loops on referrals and care plans, and partner closely with care coordinators, behavioral health specialists, and external providers.

There is significant potential for professional development and advancement within our growing organization. This role may require travel (5-10%) to various assisted living and skilled nursing facilities within the 5 boroughs.

The Role
You will screen for behavioral health needs and ensure appropriate escalation and referral, while behavioral health treatment is delivered by Horizon’s behavioral health team and external specialists.

What You Will Do:

Care Delivery & Longitudinal Management (Hybrid)

• Deliver care through a combination of in-person visits and telehealth, based on patient needs and program workflows.
• Manage chronic conditions using evidence-based care plans (e.g., HTN, DM, CHF, COPD/asthma, hyperlipidemia, obesity and other conditions aligned to program scope).
• Conduct post-hospital/ED follow-ups and medication reconciliation as appropriate; update care plans based on new events.
• Provide timely clinical responses to patient symptoms, questions, and changes in status, including escalation when needed.

CCM: Care Planning, Coordination, and Closed-Loop Follow-Up

• Develop and maintain individualized care plans in collaboration with patients and caregivers, incorporating goals, barriers, and preferences.
• Coordinate care across the full care team: PCPs, specialists, therapists, home health, community resources, and internal program staff.
• Ensure closed-loop referrals: initiate referrals, communicate clinical context, track appointment completion, receive consult notes, and incorporate recommendations into the care plan.
• Partner with families/caregivers (with appropriate consent) to support adherence, safety, and follow-through on the care plan.

RPM: Monitoring, Triage, and Action

• Review RPM dashboards and trends (e.g., BP, glucose, weight, pulse ox as applicable) and take action based on protocols.
• Triage alerts, differentiate signal vs. noise, and escalate appropriately to higher-acuity settings when indicated.
• Adjust care plans and medications (within scope and policy) based on RPM trends, patient reports, and clinical assessment.
• Provide patient education and coaching to improve adherence to monitoring and to reinforce self-management skills.

BHI: Identification, Safety, and Care Team Integration (Referral-Based Treatment)

• Use BHI screening tools and clinical assessment to identify behavioral health needs (e.g., depression/anxiety screening) and document findings.
• Coordinate warm handoffs to Horizon’s behavioral health clinicians and/or external specialists; ensure follow-up is scheduled and completed.
• Address urgent safety concerns per protocol (e.g., suicidality screening, safety planning, escalation) and communicate with appropriate team members.
• Collaborate with behavioral health team members to ensure care plans are aligned, roles are clear, and communication loops are closed.

Communication, Collaboration, and Patient/Family Experience

• Serve as a consistent clinical point of contact for patients and families/caregivers when appropriate.
• Communicate proactively with external providers and facilities (specialists, hospitals, SNFs, home care) to obtain records, clarify plans, and reduce fragmentation.
• Translate specialist recommendations into actionable steps for patients and caregivers; reinforce plan understanding and next steps.
• Maintain a patient-centered approach that builds trust, improves engagement, and supports retention in longitudinal programs.

Documentation, Quality, and Program Integrity

• Document timely and accurately to support continuity of care, compliance requirements, and program billing standards for CCM/RPM/BHI.
• Follow clinical protocols, escalation pathways, and prescribing policies (including controlled substances policies as applicable).
• Participate in case conferences, chart reviews, quality improvement activities, and workflow refinement.
• Contribute to a high-reliability clinical culture: clear handoffs, accurate problem lists/med lists, and tight follow-up on results.

Are You Someone Who Has

• Nurse Practitioner with active, unrestricted NY license (required)
• Board certification as FNP or Adult/Adult-Gerontology NP (required)
• 2+ years of clinical NP experience in ambulatory care, internal medicine, complex care, geriatrics, or similar settings (required)
• Strong chronic disease management skills and comfort making clinical decisions in a longitudinal care model (required)
• Excellent care coordination and communication skills (patients, caregivers, specialists, facilities, and internal teams)
• Strong documentation skills and comfort working in an EHR and remote monitoring workflows
• Team-oriented, highly reliable, and comfortable in a fast-moving, high-touch care environment
• Comfort working with operational metrics (engagement, follow-up timeliness, adherence to monitoring, closed-loop referrals) (preferred)

In addition to meaningful work, we offer

• Health, Vision and Dental Insurance
• 15 Days of Paid Time Off (5 of which are sick days)
• Laptop
• Flexible work schedule
• Opportunities for professional growth
• Reimbursement for travel

The base wage range for this position based in New York City is targeted at $135,000-$145,000 per year.

If you’re a dedicated clinician looking to make a meaningful difference in the lives of older adults, we invite you to apply!

Join us in providing care that truly matters.

Job Type: Full-time

Pay: $135,000.00 - $145,000.00 per year

Benefits:

• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Application Question(s):

• Please tell me more about your experience working with older adults in a clinical setting.
• Please list 2-3 dates and time ranges that you could do an interview.

Experience:

• ambulatory, internal medicine, complex care, geriatrics: 2 years (Required)

License/Certification:

• Board certification as FNP or Adult/Adult-Gerontology NP? (Required)
• Nurse Practitioner with active, unrestricted NY license (Required)

Work Location: Remote