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Nurse Practitioner in Transitional Care Management

Imagine being part of a team where every day you make an impact on someone's journey to recovery. As a Nurse Practitioner in Transitional Care Management at Legacy Community Health, you will play a pivotal role in providing advanced clinical care to patients after they've been discharged from hospitals, emergency departments, skilled nursing facilities, and more. This is your opportunity to be at the heart of patient care, ensuring continuity and promoting well-being in the outpatient setting.

• Focus on meaningful post-discharge assessments and medication reconciliation.
• Develop personalized care plans and educate patients and caregivers.
• Collaborate with interdisciplinary teams to enhance patient recovery.
• Be an integral part of reducing avoidable readmissions and supporting value-based care outcomes.

• Practice within the scope of licensure and organizational policies.
• Conduct timely post-discharge visits for recently discharged patients.
• Review essential discharge documents and patient records.
• Perform comprehensive transitional care assessments.
• Complete medication reconciliation and address discrepancies.
• Manage acute post-discharge needs and chronic conditions.
• Develop and communicate individualized post-discharge care plans.
• Identify and address gaps in care and social determinants of health.
• Provide education to patients and caregivers on key health information.
• Coordinate follow-up care with various healthcare providers and agencies.
• Float or travel to multiple clinic locations to support patient care.
• Escalate urgent clinical concerns to appropriate care team members.
• Track and monitor patient progress through the post-discharge period.
• Document all care encounters accurately in the electronic health record.
• Participate in interdisciplinary care team meetings and improvement activities.
• Stay informed on transitional care management guidelines and best practices.

• Current license from the Texas Board of Nursing and completion of program at an accredited school.
• Provider shall obtain, maintain and participate in the Medicare and Medicaid Programs, workers compensation, other federal and state reimbursement programs, and the payment plan of any commercial insurer, health maintenance organization, preferred provider organization, accountable health plan, and other health benefit program requested by Legacy.
• 2 years of experience is required.
• Previous experience in an FQHC clinic setting is preferred
• Transitional Care Management experience is preferred.
• Value Based Care/Managed Care experience highly desirable.
• Excellent communication skills and customer service skills.
• Must be able to manage multiple deadlines and prioritize.
• Demonstrated competency with an EHRS system.
• Ability to multitask in a fast-paced environment.
• Above average organizational skills.
• This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
• Bilingual / Spanish fluency desirable.

As the largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has been delivering comprehensive, high-quality, and affordable health care for nearly 40 years. With more than 50 clinics across the Greater Houston and Gulf Coast region, we continue to grow strategically and invest in our communities. By innovating how care is delivered, we've stayed at the forefront of connecting our communities to health—every day, in every way.

At Legacy, we know our success is powered by our people. We're always looking for talented, passionate individuals who want more than a job—they want a meaningful career that makes a real impact. Explore our open positions and see if a career at Legacy is right for you.

At Legacy Community Health, our mission—Driving healthy change in our communities—guides everything we do. To fulfill this mission, every team member is expected to embody the following core attributes in their daily work, regardless of role or department:

We bring our expertise without ego. In a collaborative healthcare…