Nurse Practitioner (APRN) - Transitions of Care (TOC)

Position Overview

Devoted Health is seeking a Nurse Practitioner (APRN) to join and help build our Transitions of Care (TOC) Program. This program focuses on providing virtual care to patients within the 30-day window after discharge from an acute setting (hospital or skilled nursing facility). The goal is to prevent readmissions by delivering exceptional, comprehensive wrap-around care. This role offers the opportunity to provide virtual clinical care across a wide range of diseases and acuity levels.

Requirements

• 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.
• Strong team player with a desire to work in an interdisciplinary team to provide the best care to patients.

Responsibilities

• Perform initial TOC visits:
  • Conduct comprehensive post-discharge assessment of patients’ medical conditions, medications, functional status, and psychosocial needs.
  • Complete post-discharge medication reconciliation.
  • Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME).
  • Provide appropriate disease-specific education regarding management and red flags.
  • Communicate contingency plans for worsening symptoms.
• Perform acute symptom TOC / virtual urgent care visits:
  • Focus on addressing a patient’s acute need or new symptom.
  • Diagnose and manage the patient.
  • Ensure patients receive the appropriate level of care.
• Participate in interdisciplinary TOC rounds:
  • Engage in meetings to discuss patients at highest risk of readmission.
• Collaborate with interdisciplinary team:
  • Work closely with RNs, LPNs, and clinical coordinators.
• Assist with clinical education of the overall team.
• Enhance team culture by facilitating safe, open communication across team roles.
• Utilize and provide feedback on the electronic health information system.
• Regularly participate in quality improvement projects and pilots.

About Devoted Health

At Devoted Health, our mission is to dramatically improve the health and well-being of older Americans by caring for every person like family. We are building a new kind of all-in-one healthcare company that integrates compassion, health insurance, clinical care, service, and technology to deliver high-quality, integrated healthcare. Founded in 2017, we have grown rapidly and now serve members across the United States.

Employment Type

Full time

Location Type

Not Specified

Salary

Not Specified