Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider
Core
Advanced Practice Provider delivering virtual post-discharge care to prevent hospital readmissions for patients with chronic conditions.
Role type
Mid-level clinical IC (NP/PA)
Builds
Virtual care programs for post-acute patients
Domain
Healthcare / Post-acute care / Telehealth
Required skills
Post-discharge assessment, medication reconciliation, care plan development, disease management (CHF, COPD, diabetes, HTN, pneumonia, UTI), telehealth diagnosis, interdisciplinary collaboration, quality improvement
Preferred skills
Internal medicine, urgent care, ER, hospital medicine, geriatrics, telehealth platform experience, acute/chronic exacerbation management
Technologies
Proprietary EHR, Telehealth video platforms
Responsibilities
Perform initial post-discharge assessments and medication reconciliations; Manage acute symptom visits and diagnose/treat decompensating patients; Participate in interdisciplinary rounds; Collaborate with RNs, LPNs, and coordinators; Assist with team clinical education; Facilitate safe team communication; Participate in quality improvement projects.
Seniority
Mid-level, hands-on IC