Bilingual Transitions of Care Advanced Practice Provider, NP/PA

This is a fully remote position, open to applicants in Arizona, +6 more states.

📋 Description

• Conduct thorough initial transitions-of-care visits following hospitalization.

• Evaluate medical conditions, medications, functional status, and psychosocial needs.

• Carry out medication reconciliation and enhance guideline-directed medical therapy.

• Issue prescriptions, lab, imaging, referral, home-health, and DME orders.

• Provide education specific to diseases and contingency plans for worsening symptoms.

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

• Assess, diagnose, and manage new or deteriorating symptoms in medically complex patients.

• Determine suitable care levels and escalate as necessary.

• Oversee each patient's clinical trajectory during the 30-day post-discharge period.

• Engage in interdisciplinary TOC rounds for patients at high risk of readmission.

• Collaborate with case managers, care coordinators, social workers, pharmacists, PCPs, and specialists.

• Promote safe, open communication and clear escalation processes for patients.

• Support clinical education, quality improvement initiatives, pilot programs, and EHR enhancements.

• Contribute to the development of the TOC program, team culture, and advancing clinical initiatives.

⛳️ Requirements

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

• Proficient in the acute management of chronic illnesses and ongoing outpatient chronic disease management.

• Availability to work full-time, five 8-hour days per week, Monday through Friday, from 8:30 AM to 5:00 PM; CST/MST/PST preferred.

• Active and in good standing RN and APRN licenses, or an active and in good standing Physician Assistant license.

• Required licensure and good standing in existing or future Devoted states.

• Willingness and ability to acquire necessary licenses in required states within 90 days of hire.

• Experience in internal medicine, urgent care, emergency medicine, hospital medicine, post-acute care, and/or geriatrics is preferred.

• Experience with telehealth video consultations is preferred.

• Background in managing post-transition patients and recognizing the need for immediate interventions is preferred.

• Familiarity with managing CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive crises is preferred.

• Strong interdisciplinary collaboration skills are essential.

🏝️ Benefits

• Employer-sponsored health insurance, along with dental and vision plans with minimal or no premium.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Eligibility for performance-based bonuses.

• Parental leave program.

• 401K plan.