Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider (APP)

Job Description

Schedule: This is a full-time, 5-day, 8-hour position (8:30 AM - 5:00 PM MST/PST required). Candidates must be willing and able to consistently work within Mountain Standard Time (MST) or Pacific Standard Time (PST) hours. A bit about this role: This position represents an amazing opportunity for an Advanced Practice Provider (NP/PA) to help build Devoted Medical’s Transitions of Care (TOC) Program. The TOC program provides virtual care in the 30 day window after a patient is discharged from the acute setting (hospital or skilled nursing facility). The clinical team is highly interdisciplinary and composed of coordinators, guides, nurse case managers, nurse practitioners, and a medical director. The program’s goal is to prevent readmissions by providing exceptional, comprehensive wrap-around care in the post-discharge period. The TOC APP will provide virtual clinical care for a wide range of diseases and across a wide spectrum of acuity. This position will require the ability to conduct a comprehensive post-discharge medical assessment, develop individualized care plans, and provide disease-specific clinical education regarding management and red flags. The TOC APP must also be comfortable diagnosing, managing, and monitoring decompensating patients with common readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections. The role will require significant interdisciplinary collaboration with nurse case managers, clinical guides, and clinical coordinators, all aimed at providing the best post-discharge care for patients possible. The TOC APP will also help enhance the team culture of the program by fostering a safe environment for team communication and patient escalations. Your Responsibilities and Impact will include: Perform initial TOC visits. These visits include comprehensive post-discharge assessment of patients’ medical conditions, medications, functional status, and psychosocial needs. Additional requirements include completing a post-discharge medication reconciliation, placing appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), providing appropriate disease education, communicating contingency plans for worsening symptoms, and comprehensively assessing a patient’s medical conditions. Perform acute symptom TOC / virtual urgent care visits. These are visits focused on addressing a patient’s acute need or new symptom. During these visits, NPs will be required to diagnose and manage the patient, and ensure they receive the appropriate level of care. Participate in interdisciplinary TOC rounds. This is an interdisciplinary meeting to discuss patients who are at highest risk of readmission. Work in an interdisciplinary fashion with RNs, LPNs, and clinical coordinators. Assist with the clinical education of the overall team. Enhance team culture by facilitating safe, open communication across team roles Utilize our home grown electronic health information system for visits while also providing feedback on how to improve the interface. Regularly participate in quality improvement projects and pilots. As our healthcare environment and service needs continue to evolve, this role may expand to include additional responsibilities such as supporting new clinical/organizational programs/initiatives and integrating innovative virtual care practices. We seek candidates who are adaptable, eager to learn, and comfortable working in a fast-paced, dynamic setting where change is constant. Flexibility in scope of practice and willingness to embrace new challenges are essential for success and professional growth in this role. Required skills and experience: At least 3 years of experience in hospital, post-hospital setting, or primary care setting, with clear understanding of common hospital discharge diagnoses, post-discharge needs, and the medical management required to avoid readmissions. Ability to work full-time, five-8 hour days/week (Monday-Friday, 8:30 AM - 5:00 PM MST/PST). Must be bilingual in both Spanish and English. Strong team player, with a desire to work in an interdisciplinary team to provide the best care to patients. Desired skills and experience: Experience in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics. Experience performing visits over telehealth video platforms. Experience in managing post-transitions patients and being able to identify the need for immediate interventions. Experience in managing acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations and hypertensive emergencies. Licensure and Certification: Role licensure and good standing is required in existing or future Devoted states. Able and willing to get licensed in required states within 90 days of hire. RN and APRN licenses are active and in good standing or Physician Assistant licenses are active and in good standing. Active BLS certification at time of hire and must maintain while employed at Devoted Medical.