Transitions of Care APP

Job Summary

To support a growing Transitions of Care program, the full-time Transitions of Care APP - TX, AZ, OH, FL Licensed will perform comprehensive post-discharge assessments, manage acute and chronic conditions, and collaborate with interdisciplinary teams to prevent patient readmissions, all while working remotely within Central, Mountain, or Pacific time zones.

Key responsibilities

• Conduct comprehensive initial post-discharge visits and medication reconciliations to optimize patient care
• Manage acute virtual urgent-care visits, assessing and addressing new or worsening symptoms in complex patients
• Collaborate with interdisciplinary teams to adjust care plans and enhance communication for high-risk patients

Required qualifications

• 5+ years of direct patient care experience managing geriatric populations with multiple chronic conditions
• Demonstrated ability in acute management and longitudinal outpatient chronic disease management
• Strong clinical decision-making skills in a virtual setting
• Proficiency in complex medication reconciliation and guideline-directed therapy
• Active and in-good-standing RN and APRN licenses for Nurse Practitioners or an active Physician Assistant license