Transitional Support Nurse Practitioner

We are so glad you are interested in joining Sutter Health!

Organization:

MPHS-Mills-Peninsula Medical Center

Position Overview:

Provides advanced clinical management for medically complex patients participating in the Multidisciplinary Transition Support Program (MTSP), supporting safe, coordinated transitions from hospitalization to longitudinal care in collaboration with the supervising physician. Performs comprehensive transition-focused clinical assessments, develops and directs individualized transition support plans, and provides medication management, patient and caregiver education, care coordination, and ongoing clinical reassessment to optimize continuity of care and patient outcomes.

Collaborates with physicians and the interdisciplinary team to facilitate safe transitions across the healthcare continuum. Participates in program development, quality improvement, and evaluation of the MTSP. Practices in accordance with organizational policies, evidence-based practice, the California Nurse Practice Act, and approved standardized procedures.

Job Description:

JOB

ACCOUNTABILITIES

* Performs comprehensive transition-focused clinical assessments and develops, implements, and directs individualized transition support plans for patients participating in the Multidisciplinary Transitional Support Program (MTSP).

* Provides advanced clinical management across the continuum of care to support safe, coordinated transitions from hospitalization to the patient's longitudinal care team in collaboration with the supervising physician.

* Monitors patient progress, performs ongoing clinical reassessment, modifies the plan of care as clinically indicated, and facilitates timely escalation of care.

* Performs medication reconciliation, optimizes medication management, and provides patient and caregiver education to support safe transitions of care.

* Collaborates with physicians and the interdisciplinary team to coordinate care across the healthcare continuum.

* Identifies clinical, psychosocial, and social barriers to recovery and facilitates appropriate interventions and community resources.

* Documents assessments, interventions, care plans, and patient outcomes accurately in the electronic health record.

* Supports the development, implementation, and evaluation of clinical workflows, program processes, and best practices to advance the MTSP.

* Participates in quality improvement, workflow optimization, program evaluation, and implementation of evidence-based transitional care practices.

* Practices in accordance with approved standardized procedures, organizational policies, applicable regulatory requirements, and the California Nurse Practice Act.

SKILLS AND KNOWLEDGE

* Knowledge of advanced nursing practice, clinical assessment, diagnostic reasoning, pharmacology, pathophysiology, and evidence-based management of medically complex adult patients.

* Knowledge of transitional care, care coordination, medication management, chronic disease management, and continuity across healthcare settings.

* Understanding of social determinants of health and available community resources.

* Strong communication, collaboration, critical thinking, clinical decision-making, and organizational skills.

* Proficiency with Electronic Health Record and Microsoft Office applications.

* Ability to work independently while collaborating effectively with physicians and interdisciplinary teams.

* Commitment to patient-centered care, professional accountability, continuous learning, and quality improvement.

MINIMUM QUALIFICATIONS

* Master's or Doctoral degree from an accredited Nurse Practitioner program.

* Minimum of five (5) years of inpatient Nurse Practitioner experience.

* Strong clinical assessment, diagnostic reasoning, communication, and critical thinking skills.

PREFERRED QUALIFICATIONS

* Acute Care Nurse Practitioner (AGACNP or ACNP) certification preferred.

* Experience with discharge planning or transitions of care preferred.

* Experience with Epic electronic health record preferred.

LICENSURE / CERTIFICATION

* Current California Registered Nurse license and Advanced Practice Nurse licensure.

* National Nurse Practitioner certification.

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