Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider

This is a fully remote position, open to applicants in Colorado.

📋 Description

• Conduct comprehensive initial transitions of care (TOC) visits.

• Execute detailed post-discharge evaluations of the patient's medical conditions, medications, functional status, and psychosocial requirements.

• Carry out a complete post-discharge medication reconciliation, identifying any duplicate, inappropriate, or contraindicated therapies while optimizing guideline-directed medical treatments.

• Issue appropriate orders (prescriptions, labs, imaging, referrals, home health, durable medical equipment), provide disease-specific education, and communicate clear contingency plans along with red flags for worsening symptoms.

• Perform acute and virtual urgent-care TOC visits.

• Independently evaluate, diagnose, and manage new or worsening symptoms in medically complex patients, determine the necessary level of care, and escalate when required, maintaining a decisive approach.

• Oversee the clinical trajectory throughout the 30-day period.

• Adapt and reinforce each patient's care plan in response to their changing clinical situation, priorities, and challenges, incorporating chronic disease management, symptom management, and timely adjustments to the medical regimen.

• Engage in interdisciplinary TOC rounds to discuss patients at the highest risk of readmission, collaborating closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' primary care providers and specialists.

• Foster a positive team culture by promoting safe, transparent communication across roles and supporting effective patient escalations.

• Contribute to the clinical education of the broader team, engage in quality improvement projects and pilots, and provide feedback to enhance our electronic health record (EHR).

• Adapt to an evolving environment. As service needs change, this role may expand to support new clinical and organizational initiatives.

⛳️ Requirements

• A minimum of 5 years of direct patient care experience managing primarily geriatric populations with multiple chronic, complex, comorbid conditions, across both acute and chronic scenarios.

• Proven comfort across the care continuum: managing acute chronic illnesses and providing longitudinal outpatient chronic disease management, with a strong comprehension of the connection between the two.

• Strong independent clinical decision-making skills and a proactive approach in a virtual setting—capable of recognizing deterioration and determining the next best step.

• Expertise in complex medication reconciliation and guideline-directed medical therapy, particularly for conditions such as heart failure, COPD, diabetes, atrial fibrillation/anticoagulation, and hypertension, including the ability to identify duplicate, inappropriate, or contraindicated medications and modify regimens safely.

• Proficiency in diagnosing, managing, and monitoring decompensating patients with common high-readmission conditions including heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.

• Availability to work a full-time 5-day, 8-hour schedule (Monday-Friday 8:30 AM – 5:00 PM within CST/PST/MST hours).

• A strong collaborative team player who excels in an interdisciplinary environment.

• Proficiency in both English and Spanish is required.

🏝️ Benefits

• Employer-sponsored health insurance and a dental and vision plan with low or no premium.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all roles, excluding Director and above; commission eligibility for Sales roles.

• Parental leave program.

• 401K program.

• And more....