Advanced Practice Clinician - Pb Care Coordination

Become part of the Beebe team - an inclusive team positioned in a vibrant, coastal community. Enjoy a fulfilling career as you support the health of our patients and a team focused on excellence.

The Post-Acute Care / Transitions of Care Nurse Practitioner is an advanced practice provider responsible for managing medically complex and high-risk patients as they transition from the acute care setting into the community and post-acute continuum. The NP provides proactive clinical management with an emphasis on chronic disease stabilization, medication management, early recognition and treatment of clinical deterioration, reduction of preventable hospital readmissions and avoidable emergency department utilization, and successful connection to longitudinal care.

Working collaboratively with physicians, primary care providers, specialists, care managers, pharmacists, home health, post-acute providers, and community resources, the NP serves as a clinical bridge between the hospital and the patient's next level of care.

• Evaluate high-risk patients following hospitalization, observation stays, emergency department encounters, or post-acute facility discharge.
• Review the hospitalization course, discharge plan, diagnostic results, pending tests, medication changes, and follow-up requirements.
• Perform timely post-discharge clinical assessments based on patient acuity and identified risk in post acute facilities.
• Identify gaps in the discharge plan and intervene before they result in clinical deterioration.
• Establish an individualized transition-of-care plan with the patient, caregiver, and interdisciplinary care team.
• Facilitate timely transition back to the patient's primary care provider and specialists once stabilized.
• When applicable, support Transitional Care Management requirements, including timely patient/caregiver communication, medication reconciliation, follow-up, and coordination of services.

Provide evidence-based management of patients with complex or multiple chronic conditions, including congestive heart failure, COPD and other chronic pulmonary disease, diabetes mellitus, chronic kidney disease, hypertension, cardiovascular disease, frailty, and other diagnoses associated with frequent ED utilization or hospitalization.

• Assess disease stability and progression.
• Adjust medications within scope of practice and applicable collaborative requirements.
• Monitor relevant laboratory and diagnostic findings.
• Reinforce disease‑specific self‑management and individualized action plans.
• Recognize early warning signs and intervene before symptoms progress to a higher level of care.
• Coordinate escalation to primary care, specialty care, urgent evaluation, or emergency services when clinically indicated.

• Identify patients at elevated risk for readmission or ED utilization.
• Proactively monitor patients during vulnerable care transitions.
• Provide rapid clinical assessment when a patient's condition changes.
• Develop alternatives to ED utilization when safe and clinically appropriate.
• Address common drivers of preventable utilization, including medication discrepancies, inability to obtain medications, delayed follow-up, chronic disease exacerbation, social barriers, caregiver limitations, and lack of timely clinical access.
• Review ED visits and readmissions to identify opportunities for earlier intervention and improvement in the transition plan.

• Complete comprehensive medication reconciliation following transitions of care.
• Identify duplications, omissions, contraindications, interactions, and barriers to medication…