Nurse Practitioner – Community Health & Care Transitions

Nurse Practitioner – Community Health & Care Transitions

Job Title:

Nurse Practitioner – Community Health & Care Transitions

Location:

Edmonton, AB (Clinic, Community, and Virtual)

Pay Rate:  $46–$62/hour (based on experience)

Duration:  Assignment through March 2027

Schedule:

Full-Time or Part-Time (Flexible; On-Call Required)

Summary
We are seeking an experienced Nurse Practitioner to support a targeted initiative focused on reducing hospitalizations and improving care transitions for seniors and high-risk patients. This role operates within a collaborative, community-based care model, working closely with social work, transition services, and community providers.

You will manage a focused patient roster, delivering proactive, preventative care across clinic, home, and virtual settings. This position offers a unique opportunity to combine direct patient care with care coordination and program development to improve outcomes and reduce strain on acute care systems.

What You’ll Do
Clinical Care

Provide comprehensive assessments, diagnosis, and treatment within scope of practice

Identify high-risk patients and implement proactive care plans to prevent hospitalization

Manage chronic and complex conditions with a focus on stabilization and prevention

Prescribe medications and monitor ongoing therapies

Deliver longitudinal care including follow-ups and care coordination

Provide care across clinic, community, and in-home settings

Support early interventions to reduce emergency visits and hospital admissions

Care Coordination & Transitions

Collaborate with social workers, transition teams, and hospital discharge teams

Support smooth transitions from hospital to community-based care

Address social determinants of health impacting patient stability

Connect patients with appropriate community resources and services

Act as a key contributor in reducing readmissions and improving continuity of care

Work closely with interdisciplinary teams, caregivers, and community providers

Participate in team meetings and organizational initiatives

Contribute to program development, evaluation, and quality improvement efforts

Maintain compliance with organizational policies and clinical standards

Community Engagement

Build relationships with community partners supporting seniors and vulnerable populations

Support outreach efforts, presentations, and awareness of available services

Collaborate with healthcare providers and external organizations involved in patient care

What You Bring

Master’s Degree in Nursing with active Nurse Practitioner licensure (Adult or Family All Ages) in Alberta, CA

5–7 years of experience in primary care or community-based healthcare settings

Strong experience managing complex, high-risk, or vulnerable patient populations

Experience with care transitions, discharge planning, or community care models

Strong clinical judgment with a focus on prevention and risk identification

Excellent communication, organization, and collaboration skills

Ability to work independently in community settings and as part of a multidisciplinary team

Proficiency with electronic health records and digital tools

Bonus Points If You Have

Additional certifications in geriatrics, diabetes education, or palliative care

Experience in community outreach and stakeholder engagement

Familiarity with continuous quality improvement (CQI) initiatives

Experience supporting seniors’ health programs or population health initiatives

TCWGlobal is an equal opportunity employer. We do not discriminate based on age, ethnicity, gender, nationality, religious belief, or sexual orientation.

#J-18808-Ljbffr