Texas Licensed Transitions of Care APP

Job Summary

To support a growing Transitions of Care program, the full-time Texas Licensed Transitions of Care APP will perform comprehensive post-discharge assessments, manage acute virtual care visits, and collaborate with interdisciplinary teams to prevent patient readmissions in a remote setting.

Key responsibilities

• Conduct thorough initial post-discharge assessments and medication reconciliations for patients
• Independently assess and manage new or worsening symptoms in medically complex patients during virtual urgent-care visits
• Collaborate with interdisciplinary teams to adjust care plans and enhance patient outcomes over a 30-day period

Required qualifications

• 5+ years of direct patient care experience managing geriatric populations with chronic, complex conditions
• Active and in-good-standing RN and APRN licenses for Nurse Practitioners or an active Physician Assistant license
• Proficiency in English and Spanish is required
• Strong clinical decision-making skills in both acute and chronic care settings
• Ability to work a full-time schedule of 8:30 AM - 5:00 PM within CST, MST, or PST time zones