260,000+ live roles 14,000+ active employers ✦ 560+ posted in 24h California market · 20,527 jobs Texas market · 18,029 jobs Florida market · 16,109 jobs New York market · 13,275 jobs California jobs · 20,527 Texas jobs · 18,029 Florida jobs · 16,109 New York jobs · 13,275 Healthcare · 119,038 jobs Patient Care · 109,714 jobs BLS · 52,660 jobs Registered Nurse · 47,913 jobs Documentation · 25,829 jobs CPR · 24,355 jobs 260,000+ live roles 14,000+ active employers ✦ 560+ posted in 24h California market · 20,527 jobs Texas market · 18,029 jobs Florida market · 16,109 jobs New York market · 13,275 jobs California jobs · 20,527 Texas jobs · 18,029 Florida jobs · 16,109 New York jobs · 13,275 Healthcare · 119,038 jobs Patient Care · 109,714 jobs BLS · 52,660 jobs Registered Nurse · 47,913 jobs Documentation · 25,829 jobs CPR · 24,355 jobs

Loading market signalLoading market signalLoading market signalLoading market signalLoading market signalLoading market signalLoading market signalLoading market signalLoading market signalLoading market signal

Nurse Practitioner, Care Transitions (Dual Board-Certified)

Quick overview

Serve as the billing provider for 30-day Transitional Care Management episodes, conducting virtual and in-person post-discharge visits for Medicare-age adults. Responsibilities include medication reconciliation, clinical risk stratification, and coordinating handoffs to behavioral health and chronic disease programs.

Requirements summary

Requires an active Maryland NP license, a postgraduate degree (MSN or DNP), and dual board certification in both psychiatric/mental health and adult primary or acute care. Candidates must have 3+ years of independent NP experience and a valid driver's license for mobile field visits.

postgraduate degreeGeriatric CareClinical DocumentationInterdisciplinary CollaborationCMS ComplianceTelehealthMedication ReconciliationChronic Disease ManagementAdult Primary CareBehavioral Health AssessmentTransitional Care ManagementPsychiatric Mental Health CareClinical Risk Stratification

Job description

Role Overview You’ll serve as the billing provider for Avail Health’s 30-day TCM episode — conducting comprehensive post-discharge visits, primarily virtual, within 1–14 days of hospital discharge. Your patients are Medicare-age adults navigating complex medical and behavioral health needs after a hospitalization. Your job is to assess, stabilize, and connect them to the right next level of care before the window closes. You’ll work inside a tight interdisciplinary team (RN Care Manager, SW Care Manager, Care Coordinator) supported by HIE integrations and an ambient AI scribe. The workflow overhead is handled. You focus on the clinical judgment. This is a founding role in a newly launching program. You’ll help build the model, not just run it. What You'll Own
The TCM billing encounter and CMS compliance for each patient’s 30-day episode
Medication reconciliation decisions and prescription authority within your scope
Clinical risk stratification at the point of the TCM visit and escalation when patients need a higher level of care What You'll Do
Conduct virtual TCM visits within 1–14 days of discharge; conduct mobile in-person visits when patients can’t be seen remotely
Perform medication reconciliation and document moderate- to high-complexity MDM at the time of each TCM encounter
Apply dual-specialty (medical + behavioral health) judgment to assess complexity and initiate the right post-discharge intervention
Facilitate warm handoffs into behavioral health, dementia care management, and chronic disease programs for qualifying patients
Participate in daily team huddles to review the panel, flag high-risk cases, and align on care priorities
Complete visit documentation same-day using an ambient AI scribe; ensure full CMS billing compliance What Success Looks Like
TCM visits completed within the 1–14 day post-discharge window for 95%+ of assigned patients
Medication reconciliation documented at the time of the TCM visit for 100% of assigned patients
30-day readmission rate for assigned panel at or below program benchmarks
Warm handoffs initiated for all clinically eligible patients within the TCM episode
Clinical documentation completed same-day with billing elements accurate and audit-ready What You'll Bring Required:
Active Maryland NP license; MSN or DNP from an accredited program

Benefits

Dental Insurance
Vision Insurance
Medical Insurance
HSA
401(k) With Employer Match
15 Days PTO
Professional Liability And Malpractice Insurance
8 + 1 Floating Holidays

Nurse Practitioner, Care Transitions (Dual Board-Certified)

Quick overview

Requirements summary

Job description

Benefits

Preferred

Salary Range

More openings at Avail Health

More district openings

Similar live jobs