[Hiring] Bilingual Transitions of Care Advanced Practice Provider @Devoted Health

Role Description

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
• 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, including comprehensive post-discharge assessment of patients’ medical conditions, medications, functional status, and psychosocial needs.
• Complete a post-discharge medication reconciliation, place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide appropriate disease education, and communicate contingency plans for worsening symptoms.
• Perform acute symptom TOC / virtual urgent care visits focused on addressing a patient’s acute need or new symptom.
• Participate in interdisciplinary TOC rounds 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 providing feedback on how to improve the interface.
• Regularly participate in quality improvement projects and pilots.
• Support new clinical/organizational programs/initiatives and integrate innovative virtual care practices as the healthcare environment evolves.

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.

Qualifications

• At least 3 years of experience in a hospital, post-hospital setting, or primary care setting.
• 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; CST/PST/MST preferred), including one weekend shift per month.
• Strong team player, with a desire to work in an interdisciplinary team to provide the best care to patients.
• Role licensure and good standing is required in existing or future Devoted states.
• 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.

Requirements

• 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 identifying the need for immediate interventions.
• Experience in managing acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive emergencies.

Benefits

• Employer sponsored health, dental and vision plan with low or no premium.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles.
• Parental leave program.
• 401K program.
• And more...