Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider
Core
Advanced Practice Provider (Nurse Practitioner or Physician Assistant) delivering virtual post-discharge care to prevent hospital readmissions for medically complex patients over a 30-day window.
Role type
Senior IC Advanced Practice Provider (Transitions of Care)
Builds
Virtual care program for high-risk post-discharge patients
Domain
Healthcare / Transitions of Care / Chronic Disease Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute clinical judgment, longitudinal chronic care management, medication reconciliation, guideline-directed medical therapy, interdisciplinary collaboration, virtual care delivery, program building
Preferred skills
Internal medicine, hospital medicine, post-acute/SNF medicine, urgent care, emergency medicine, geriatrics, palliative care, primary care, telehealth platform experience, frail/vulnerable population management
Technologies
Homegrown EHR, telehealth video platforms
Responsibilities
Perform comprehensive initial post-discharge assessments and medication reconciliation; manage acute/virtual urgent-care visits for decompensating patients; adjust care plans across the 30-day window; participate in interdisciplinary rounds; enhance team culture and communication; assist with clinical education and quality-improvement projects
Seniority
Senior, hands-on IC