Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider
Core
Advanced Practice Provider delivering virtual post-discharge clinical care to prevent patient readmissions across a wide spectrum of acuity and diseases.
Role type
Senior IC Advanced Practice Provider (NP/PA)
Builds
Virtual Transitions of Care program for post-acute patients
Domain
Healthcare / Post-acute care / Telehealth
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Post-discharge medical assessment, medication reconciliation, care plan development, disease-specific education, diagnosis and management of decompensating patients, interdisciplinary collaboration, virtual urgent care management
Preferred skills
Internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, geriatrics, telehealth video platforms, acute/chronic disease exacerbation management
Technologies
Home grown electronic health information system
Responsibilities
Perform initial post-discharge assessments and medication reconciliations; conduct acute symptom virtual urgent care visits; participate in interdisciplinary rounds for high-risk patients; collaborate with RNs, LPNs, and coordinators; assist with team clinical education; facilitate safe team communication; participate in quality improvement projects
Seniority
Mid-Senior level, hands-on IC