Transitions of Care Advanced Practice Provider – NP, PA

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

📋 Description

• Develop and maintain the Transitions of Care program, delivering virtual care during the 30 days following hospital discharge.

• Conduct thorough initial post-discharge assessments, covering medical, medication, functional, and psychosocial factors.

• Perform medication reconciliation and enhance guideline-directed medical therapy.

• Issue prescriptions, laboratory tests, imaging, referrals, home health, and durable medical equipment orders.

• Offer disease-specific education and create contingency plans for worsening symptoms.

• Execute acute and virtual urgent care visits for new or escalating symptoms.

• Evaluate, diagnose, manage, and refer medically complex patients to the appropriate care level.

• Oversee each patient's clinical journey throughout the 30-day period.

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

• Collaborate with RN case managers, care coordinators, social work managers, pharmacy, primary care providers, specialists, and patients.

• Promote safe, transparent communication and support patient escalations.

• Contribute to clinical education, quality improvement initiatives, and pilot projects.

• Provide insights for enhancing the proprietary electronic health record system.

• Support ongoing clinical and organizational initiatives in a fast-paced, dynamic development environment.

⛳️ Requirements

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

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

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

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

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

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

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

• Familiarity with telehealth video platforms for conducting visits is desired.

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

• Background in handling CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive crises is preferred.

🏝️ Benefits

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

• Generous paid time off policy.

• Monthly stipend of $100 for mobile or internet expenses.

• Stock options available for all employees.

• Eligibility for bonuses in all positions excluding Director and above.

• Parental leave program offered.

• 401K retirement plan available.