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

Job Description Schedule

This is a full-time, 5-day, 8-hour position (8:30 AM – 5:00 PM CST/MST/PST). Candidates must be able to consistently work within Central (CST), Mountain (MST), or Pacific (PST) time zone hours.

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.

This role demands two distinct skill sets in one provider. 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 should be equally comfortable deciding whether a patient needs an immediate intervention today and managing the slower arc of their chronic disease across the continuum. 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.

• Perform comprehensive initial TOC visits. 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 escalate when needed — with a clear bias to action.

• Manage the clinical trajectory across the 30‑day window. 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.

• 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 our EHR.

• Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives. We seek people who are adaptable, eager to learn, and comfortable in a fast‑paced, dynamic setting where change is constant.

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

• Demonstrated comfort across the continuum: acute management of chronic illness and longitudinal outpatient chronic‑disease management, with a strong understanding of how the two connect.

• Strong, independent clinical decision‑making and bias to action in a virtual setting — comfortable being the clinician who recognizes deterioration and decides the next best…