Transitions of Care Advanced Practice Provider

**Job Description** **Schedule** This is a full\-time, 5\-day, 8\-hour position (8:30 AM – 5:00 PM CST/MST/PST). Candidates must be able to consistently work within Central (CST), Mountain (MST), or Pacific (PST) time zone hours. **A bit about this role** Our Devoted Medical Transitions of Care (TOC) Advanced Practice Provider (APP) roles include both Nurse Practitioners (APRNs) and Physician Assistants (PAs) — candidates for both will be considered. This is an opportunity for an experienced APP to help build the TOC Program. The TOC program provides virtual care during the 30\-day window after a patient is discharged from a hospitalization. Our goal is to prevent readmissions by delivering exceptional, comprehensive, wrap\-around care during this high\-risk period. The team is highly interdisciplinary — care coordinators, nurse case managers, social workers, APPs, and physicians collaborating together. This role demands two distinct skill sets in one provider. Roughly 70% of your time is spent on comprehensive initial post\-discharge visits, and 30% on follow\-up and acute/urgent symptom visits. That means you need the ***acute*** **clinical judgment to** **recognize and manage a decompensating, medically complex patient in real time,** **and** **the** ***longitudinal*** **depth to build and adjust a whole\-person, complex chronic\-care plan over 30 days**. You should be equally comfortable deciding whether a patient needs an immediate intervention today and managing the slower arc of their chronic disease across the continuum. You'll also help build the program itself — shaping team culture, fostering safe and open communication, contributing to quality\-improvement work, and giving feedback on our homegrown EHR as we grow. **Responsibilities and impact will include:** * Perform comprehensive initial TOC visits. Conduct a thorough post\-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. Complete a full post\-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline\-directed medical therapy. Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease\-specific education, and communicate clear contingency plans and red flags for worsening symptoms. * Perform acute / virtual urgent\-care TOC visits. Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action. * Manage the clinical trajectory across the 30\-day window. Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen. * Participate in interdisciplinary TOC rounds to discuss patient