Transitions of Care Advanced Practice Provider

This is a fully remote position, open to applicants in Arizona, +5 more states.

📋 Description

• Deliver virtual care within the 30 days following patients' discharge from a hospital or skilled nursing facility.

• Conduct initial transitions-of-care visits, which encompass thorough post-discharge evaluations of medical conditions, medications, functional status, and psychosocial needs.

• Execute post-discharge medication reconciliation and issue necessary orders for prescriptions, labs, imaging, referrals, home health, and DME.

• Provide disease-specific education and outline contingency plans for worsening symptoms.

• Conduct acute symptom transitions-of-care and virtual urgent care visits, diagnosing and managing patients while ensuring appropriate levels of care.

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

• Collaborate with RNs, LPNs, nurse case managers, clinical guides, and clinical coordinators.

• Support the clinical education of the entire team.

• Promote safe, open communication across team roles and assist with patient escalations.

• Utilize Devoted Medical’s electronic health information system and offer feedback for interface improvements.

• Participate in quality improvement initiatives and pilot projects.

• Assist in the support of new clinical or organizational programs and initiatives, integrating innovative virtual care practices as the role develops.

⛳️ Requirements

• Minimum of 3 years of experience in a hospital, post-hospital, or primary care setting, with a solid understanding of common hospital discharge diagnoses, post-discharge requirements, and the medical management needed to prevent readmissions.

• Must be able to work full-time, five 8-hour days per week (Monday-Friday, 8:30 AM - 5:00 PM; CST/MST/PST preferred), including one weekend shift per month.

• Strong team player with a commitment to working in an interdisciplinary team to provide optimal patient care.

• Role licensure and good standing are required in current or future Devoted states.

• Must be able and willing to obtain licensure in required states within 90 days of hire.

• RN and APRN licenses must be active and in good standing, or Physician Assistant licenses must be active and in good standing.

• Active BLS certification at the time of hire is required and must be maintained while employed at Devoted Medical.

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

• Familiarity with conducting visits via telehealth video platforms.

• Experience managing post-transition patients and identifying the need for immediate interventions.

• Experience handling acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive emergencies.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans 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.