Bilingual – Transitions of Care Advanced Practice Provider

This is a fully remote position, open to applicants in Arizona, +3 more states.

📋 Description

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

• Perform an in-depth post-discharge evaluation of the patient's medical conditions, medications, functional status, and psychosocial requirements.

• Execute a thorough post-discharge medication reconciliation — identifying duplicate, inappropriate, or contraindicated therapies and optimizing treatment in line with clinical guidelines.

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

• Conduct acute and virtual urgent-care transitions of care visits.

• Independently evaluate, diagnose, and manage new or worsening symptoms in medically complex patients, determine the necessary level of care, and escalate as required — with a strong emphasis on taking action.

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

• Adapt and reinforce each patient's care plan in response to their changing clinical status, priorities, and challenges — including chronic disease management, symptom management, and timely adjustments to the treatment 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 the 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 insights to enhance our electronic health record system.

• Embrace a dynamic environment. As service needs evolve, this position may expand to encompass 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 presentations.

• Proven comfort across the care continuum: acute management of chronic illnesses and long-term outpatient chronic disease management, with a deep understanding of how they interrelate.

• Strong, independent clinical decision-making skills and a proactive approach in a virtual setting — confident in identifying deterioration and determining the next best course of action.

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

• Proficient in diagnosing, managing, and monitoring decompensating patients with prevalent high-readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.

• Ability to commit to a full-time, 5-day, 8-hour work 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.

• Fluency in both English and Spanish is required.

🏝️ Benefits

• Employer-sponsored health insurance, along with dental and vision plans with 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 roles, excluding Director and above; commission eligibility for Sales positions.

• Parental leave program.

• 401K program.

• And more...