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.

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

• Carry out a complete post-discharge medication reconciliation, identifying any duplicate, inappropriate, or contraindicated therapies while optimizing guideline-directed medical treatment.

• Place necessary orders (including prescriptions, labs, imaging, referrals, home health, and durable medical equipment), provide education specific to diseases, and communicate clear contingency plans and warning signs for symptom deterioration.

• Conduct acute and virtual urgent-care TOC visits.

• Independently evaluate, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when necessary, demonstrating a clear bias towards action.

• Oversee the clinical trajectory over a 30-day period.

• Adjust and reinforce each patient’s care plan according to their changing clinical status, priorities, and challenges, focusing on chronic disease management, symptom relief, and timely updates to the medical regimen.

• Engage in interdisciplinary TOC rounds to discuss patients at the highest risk of readmission and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and the patients' primary care physicians and specialists.

• Foster a positive team culture by promoting safe, open communication across roles and facilitating clear patient escalations.

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

• Adapt to a dynamic environment. As service needs evolve, this role may broaden to support new clinical and organizational initiatives. We are looking for individuals who are flexible, eager to learn, and comfortable in a fast-paced, ever-changing setting.

⛳️ Requirements

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

• Proven ability to navigate the continuum of care, including acute management of chronic illnesses and ongoing outpatient chronic disease management, with a robust understanding of their interconnection.

• Strong clinical decision-making skills and a proactive approach in a virtual environment, being confident in recognizing patient deterioration and determining the next appropriate steps.

• 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 identify duplicate, inappropriate, or contraindicated medications and adjust regimens safely.

• Comfort in diagnosing, managing, and monitoring patients at risk of decompensation with common high-readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.

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

• A strong collaborator who excels in an interdisciplinary team environment.

🏝️ Benefits

• Employer-sponsored health insurance along with dental and vision plans with low or no premiums.

• Generous paid time off policy.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available for all employees.

• Bonus eligibility for all positions except for Director level and above; commission eligibility for Sales roles.

• Parental leave program offered.

• 401K program available.

• And much more....