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 co