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 manage comprehensive post-discharge visits, conduct acute virtual care assessments, and collaborate with interdisciplinary teams to enhance patient outcomes in a fully remote setting.

Key responsibilities

• Perform comprehensive initial post-discharge assessments and medication reconciliations for patients
• Independently assess and manage acute or worsening symptoms in medically complex patients during virtual visits
• Adjust and reinforce care plans across the 30-day post-discharge period, addressing evolving clinical needs and barriers

Required qualifications

• 5+ years of direct patient care experience managing geriatric populations with complex chronic conditions
• Active and in good standing RN and APRN licenses or active PA license, with the ability to obtain licensure in required states within 90 days of hire
• Demonstrated experience in both acute management and longitudinal chronic disease management
• Ability to work full-time, five 8-hour days per week, preferably Monday-Friday
• Experience with telehealth platforms for patient visits