Advanced Practice Provider Emergency Care Department

Our Devoted Medical Transitions of Care (TOC) Advanced Practice Provider (APP) roles include both Nurse Practitioners (APRNs) and Physician Assistants (PAs) — candidates for both will be considered. This is an opportunity for an experienced APP to help build the TOC Program. The TOC program provides virtual care during the 30-day window after a patient is discharged from a hospitalization. Our goal is to prevent readmissions by delivering exceptional, comprehensive, wrap-around care during this high-risk period.

The team is highly interdisciplinary — care coordinators, nurse case managers, social workers, APPs, and physicians collaborating together.

Roughly 70% of your time is spent on comprehensive initial post-discharge visits, and 30% on follow-up and acute/urgent symptom visits. That means you need the acute clinical judgment to recognize and manage a decompensating, medically complex patient in real time, and the longitudinal depth to build and adjust a whole-person, complex chronic-care plan over 30 days . You'll also help build the program itself — shaping team culture, fostering safe and open communication, contributing to quality-improvement work, and giving feedback on our homegrown EHR as we grow.

Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms.

Perform acute / virtual urgent-care TOC visits. Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and elevate when needed — with a clear bias to action.

Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen.

Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists.

Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR.

5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions — across both acute and chronic presentations.

~ Ability to work full-time, five-8 hour days/week (Monday-Friday, 8:30 AM - 5:00 PM; RN and APRN licenses are active and in good standing or Physician Assistant licenses are active and in good standing. Experience in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics.

Experience performing visits over telehealth video platforms. Experience in managing acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations and hypertensive emergencies.

Strong team player, with a desire to work in an interdisciplinary team to provide the best care to patients.

120,000-$150,000/year plus performance based bonus paid out quarterly or annually ($10K-$20K) for a total comp range of $130,000-$170,000/year.

Employer-sponsored health insurance and dental and vision plan with low or no premium

The pay range listed for this position is the range the organization reasonably…