Telehealth Transitional Care Nurse Practitioner

This is a fully remote position, open to applicants in California, +8 more states.

📋 Description

• Conduct telehealth visits for Transitional Care Management within 14 days post-discharge.

• Execute thorough clinical assessments for members who have recently been discharged.

• Perform medication reconciliation while identifying concerns related to safety, adherence, and continuity of care.

• Assist members and caregivers with steps for connecting to video visits and provide basic troubleshooting support.

• Recognize acute clinical needs and escalate urgent findings in accordance with clinical protocols.

• Act as a primary clinical escalation resource for care coordinators and support staff.

• Collaborate with primary care providers, specialists, and discharge planning teams to address care gaps and minimize readmission risks.

• Adjust the sequence of daily visits based on cancellations, discharge timings, and care priorities.

• Ensure comprehensive and accurate documentation of all encounters.

• Submit charts by the service date for coding, quality reporting, and claims processing.

• Uphold compliance with HIPAA regulations, state licensure, and payer-specific documentation requirements.

• Engage in clinical training, chart audit feedback sessions, and quality improvement initiatives.

⛳️ Requirements

• Valid, unrestricted Nurse Practitioner licensure in at least three of the following states: Ohio, California, New York, Indiana, Kentucky, Pennsylvania, Louisiana, Michigan, Tennessee, Missouri.

• Current national board certification through AANP or ANCC as a Family Nurse Practitioner (FNP), Adult Gerontology Nurse Practitioner (AGNP), or an equivalent adult/geriatric-focused certification.

• At least 2 years of clinical experience.

• Comfortable delivering care via video visits and effectively communicating with members and caregivers from a distance.

• Ability to maintain a reliable weekday schedule with rotating weekend coverage for urgent or emergent clinical needs.

• Proficient in using EMR documentation platforms, video-visit software, and desktop or mobile point-of-care technology.

• Capable of completing accurate same-day documentation for all patient encounters.

• Possess a dedicated, private, HIPAA-compliant workspace.

• Reliable high-speed internet connection that supports uninterrupted video visits.

• Personal computer and webcam setup that accommodates secure video visits and clinical documentation tools.

• Ability to remain seated, focused, and engaged on camera for consecutive video visits.

• Prior experience in telemedicine or telehealth is preferred.

• Experience in Transitional Care Management or post-discharge care is preferred.

• Familiarity with Medicare Advantage populations is preferred.

• Knowledge of HEDIS, STAR measures, and value-based care documentation standards is preferred.

• Experience in a fast-paced, discharge-driven scheduling environment is preferred.

🏝️ Benefits

• Salary of $135,000.

• Remote/telehealth work model.

• Full-time, exempt position.

• Core weekday hours from Monday to Friday.

• Rotating weekend coverage for urgent or emergent needs.

• Continuous clinical training provided.

• Participation in chart audit feedback sessions.

• Involvement in quality improvement initiatives.