Bilingual; Spanish​/English) Transitions of Care Advanced Practice Provider

Schedule

Full‑time, 5‑day, 8‑hour position (8:30 AM – 5:00 PM CST/MST/PST). Candidates must consistently work within Central, Mountain, or Pacific time zone hours.

As a Devoted Medical Transitions of Care (TOC) Advanced Practice Provider (APP), you will help build the program and provide virtual care during the 30‑day window after a patient is discharged. The goal is to prevent readmissions through comprehensive, wrap‑around care delivered by a highly interdisciplinary team.

• Perform comprehensive initial TOC visits, conducting a thorough post‑discharge assessment of medical conditions, medications, functional status, and psychosocial needs.
• Complete post‑discharge medication reconciliation, identify duplicate, inappropriate, or contraindicated therapy, and optimize guideline‑directed medical therapy.
• Place appropriate orders (prescriptions, labs, imaging, referrals, home health, durable medical equipment), provide disease‑specific education, and communicate clear contingency plans and red flags for worsening symptoms.
• Conduct acute/virtual urgent‑care TOC visits, independently assessing, diagnosing, and managing new or worsening symptoms in medically complex patients.
• Manage the clinical trajectory across the 30‑day window, reinforcing and adjusting each patient’s plan of care in response to evolving clinical picture, priorities, and barriers.
• Participate in interdisciplinary TOC rounds, collaborating closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients’ primary care providers and specialists.
• Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations.
• Assist with clinical education of the broader team, participate in quality‑improvement projects and pilots, and provide feedback to improve the EHR.
• Adapt to evolving clinical and organizational initiatives as the service grows.

• 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions across acute and chronic presentations.
• Demonstrated comfort managing the continuum of care: acute management of chronic illness and longitudinal outpatient chronic‑disease management.
• Strong, independent clinical decision‑making and bias to action in a virtual setting.
• Proficiency with complex medication reconciliation and guideline‑directed medical therapy, especially for heart failure, COPD, diabetes, atrial fibrillation/anticoagulation, and hypertension.
• Comfort diagnosing, managing, and monitoring decompensating patients with high‑readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.
• Ability to work the full‑time 5‑day, 8‑hour schedule (Monday‑Friday 8:30 AM – 5:00 PM within CST/PST/MST hours).
• Strong team player who thrives in an interdisciplinary environment.
• Proficiency in English and Spanish required.

• Experience in internal medicine, hospital medicine, post‑acute/SNF medicine, urgent care or emergency medicine, geriatrics, palliative care, and/or primary care with a strong chronic disease management focus.
• Experience managing acute and chronic disease exacerbations, including CHF, COPD, diabetic emergencies, and hypertensive emergencies, and identifying the need for immediate intervention.
• Experience performing visits over telehealth video platforms.
• Experience working with frail, complex, or vulnerable populations, including in the skilled nursing facility (SNF) setting.
• Continuous‑improvement mentality, can‑do attitude, and ability to adapt quickly to new workflows and changes.

For Nurse Practitioners:…