Telehealth Transitional Care Nurse Practitioner
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Job Description
Telehealth Nurse Practitioner delivering Transitional Care Management visits after discharge. Assessing members, reconciling medications, coordinating care, and reducing avoidable readmissions across multiple U.S. states.
Responsibilities:
- Conduct Transitional Care Management telehealth visits within 14 days of discharge
- Perform comprehensive clinical assessments for recently discharged members
- Complete medication reconciliation and identify safety, adherence, and care-continuity concerns
- Support members and caregivers with video visit connection steps and basic troubleshooting
- Identify acute clinical needs and escalate urgent findings according to clinical protocols
- Serve as a first-line clinical escalation resource for care coordinators and support staff
- Coordinate with PCPs, specialists, and discharge planning teams to close care gaps and reduce readmission risk
- Adjust daily visit sequencing based on cancellations, discharge timing, and care priorities
- Document all encounters completely and accurately
- Submit charts by the date of service for coding, quality reporting, and claims submission
- Maintain compliance with HIPAA, state licensure, and payer-specific documentation requirements
- Participate in clinical training, chart audit feedback sessions, and quality improvement initiatives
Requirements:
- Active, unrestricted Nurse Practitioner licensure in at least three of: Ohio, California, New York, Indiana, Kentucky, Pennsylvania, Louisiana, Michigan, Tennessee, Missouri
- Active national board certification through AANP or ANCC as an FNP, AGNP, or equivalent adult/geriatric-focused certification
- Minimum of 2 years of clinical experience
- Comfort delivering care through video visits and communicating with members and caregivers remotely
- Ability to work a dependable weekday schedule with rotating weekend coverage for urgent or emergent clinical needs
- Strong comfort using EMR documentation platforms, video-visit software, and desktop or mobile point-of-care technology
- Ability to complete accurate same-day documentation for all encounters
- Dedicated, private, HIPAA-compliant workspace
- Reliable high-speed internet connection suitable for uninterrupted video visits
- Personal computer and webcam setup supporting secure video visits and clinical documentation tools
- Ability to remain seated, attentive, and engaged on camera for consecutive video visits
- Prior telemedicine or telehealth experience preferred
- Transitional Care Management or post-discharge care experience preferred
- Experience with Medicare Advantage populations preferred
- Familiarity with HEDIS, STAR measures, and value-based care documentation standards preferred
- Experience in a fast-paced, discharge-driven scheduling environment preferred
Benefits:
- $135,000 salary
- Remote / telehealth work model
- Full-time, exempt position
- Core weekday hours, Monday through Friday
- Rotating weekend coverage for urgent or emergent needs
- Ongoing clinical training
- Chart audit feedback sessions
- Quality improvement initiatives
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