Bilingual, Spanish/English Transitions of Care Advanced Practice Provider

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

📋 Description

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

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

• Perform a complete post-discharge medication reconciliation, identifying any duplicate, inappropriate, or contraindicated therapies, and optimizing guideline-directed medical therapies.

• Issue necessary orders (such as prescriptions, labs, imaging, referrals, home health, and durable medical equipment), deliver disease-specific education, and clearly communicate contingency plans along with warning signs for worsening symptoms.

• Carry out acute and virtual urgent-care TOC visits.

• Independently evaluate, diagnose, and manage new or exacerbated symptoms in patients with complex medical histories, determine the suitable level of care, and escalate as necessary, maintaining a strong bias towards action.

• Oversee the clinical trajectory within a 30-day timeframe.

• Adapt and reinforce each patient's care plan based on their changing clinical circumstances, priorities, and obstacles, including chronic disease management, symptom management, and timely adjustments to their medical regimen.

• Engage in interdisciplinary TOC rounds to review patients at elevated 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, open communication across roles and supporting effective patient escalations.

• Contribute to the clinical education of the wider team, participate in quality improvement initiatives and projects, and provide feedback to enhance our electronic health record (EHR) system.

• Embrace a dynamic environment. As service demands evolve, this role may expand to encompass new clinical and organizational initiatives.

⛳️ Requirements

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

• Proven comfort with managing the continuum of care: acute management of chronic illnesses and long-term outpatient chronic disease management, with a strong grasp of their interconnection.

• Strong independent clinical decision-making skills and a bias toward action in a virtual environment—capable of recognizing deterioration and determining the next appropriate steps.

• Expertise in complex medication reconciliation and guideline-directed medical therapies, 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 make safe regimen adjustments.

• Proficient 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 schedule of 5 days a week, 8 hours per day (Monday-Friday, 8:30 AM – 5:00 PM within CST/PST/MST hours).

• A collaborative team player who excels in an interdisciplinary setting.

• Proficiency in both English and Spanish is required.

🏝️ Benefits

• Employer-sponsored health insurance, along with a dental and vision plan featuring low or no premiums.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all positions excluding Director and above; Commission eligibility for Sales roles.

• Parental leave program.

• 401K retirement plan.

• And more....