Transitions of Care Advanced Practice Provider – NP, PA
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Job Description
Virtual Transitions of Care APP providing post-discharge and urgent care for Devoted Health’s older members. Managing complex conditions, preventing readmissions, and shaping an interdisciplinary care program.
Responsibilities:
- Build and support the Transitions of Care program providing virtual care during the 30-day period after hospital discharge
- Perform comprehensive initial post-discharge visits, including medical, medication, functional, and psychosocial assessments
- Complete medication reconciliation and optimize guideline-directed medical therapy
- Place prescriptions, lab, imaging, referral, home health, and DME orders
- Provide disease-specific education and contingency plans for worsening symptoms
- Perform acute and virtual urgent-care TOC visits for new or worsening symptoms
- Assess, diagnose, manage, and escalate medically complex patients to the appropriate level of care
- Manage each patient's clinical trajectory throughout the 30-day window
- Participate in interdisciplinary TOC rounds for patients at highest risk of readmission
- Collaborate with RN case managers, care coordinators, social work case managers, pharmacy, PCPs, specialists, and patients
- Facilitate safe, open communication and support patient escalations
- Assist with clinical education, quality-improvement projects, and pilots
- Provide feedback to improve the homegrown EHR
- Support evolving clinical and organizational initiatives in a fast-paced, dynamic build environment
Requirements:
- 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions across acute and chronic presentations
- Demonstrated comfort with acute management of chronic illness and longitudinal outpatient chronic-disease management
- Ability to work full-time, five 8-hour days per week, Monday-Friday, 8:30 AM-5:00 PM; CST/MST/PST preferred
- Active and in-good-standing RN and APRN licenses, or active and in-good-standing Physician Assistant license
- Role licensure and good standing required in existing or future Devoted states
- Able and willing to obtain licenses in required states within 90 days of hire
- Experience in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics desired
- Experience performing visits over telehealth video platforms desired
- Experience managing post-transitions patients and identifying the need for immediate interventions desired
- Experience managing CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive emergencies desired
Benefits:
- Employer-sponsored health insurance and dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above
- Parental leave program
- 401K program
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