Transitions of Care Advanced Practice Provider

About This Opportunity

We are representing a confidential healthcare organization seeking a Transitions of Care Advanced Practice Provider to help build and deliver virtual post-discharge care. This is a remote position based in the United States.

Our client operates an interdisciplinary Transitions of Care program that provides virtual clinical support during the critical 30-day window after hospital or skilled nursing facility discharge. The goal is to prevent readmissions through comprehensive, patient-centered care coordination.

As a TOC APP, you will deliver virtual clinical assessments, develop individualized care plans, and manage a range of acute and chronic conditions remotely. You'll collaborate closely with nurse case managers, care coordinators, and clinical guides to ensure patients receive seamless support during their recovery.

Responsibilities

• Conduct comprehensive virtual post-discharge assessments including medical status, medications, functional capacity, and psychosocial needs
• Perform medication reconciliation and place orders for prescriptions, labs, imaging, referrals, home health services, and durable medical equipment
• Provide virtual urgent care visits to address acute symptoms and new medical concerns
• Diagnose and manage common readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections
• Deliver disease-specific patient education on management strategies and warning signs
• Participate in interdisciplinary rounds to discuss high-risk patients and care coordination
• Collaborate with RNs, LPNs, and clinical coordinators across the care team
• Contribute to clinical education for team members and quality improvement initiatives
• Foster a culture of safe communication and effective patient escalation
• Provide feedback on electronic health record systems and workflows

What We're Looking For

Required:

• Active Nurse Practitioner or Physician Assistant license in good standing
• At least 3 years of experience in hospital, post-acute, or primary care settings with knowledge of common discharge diagnoses and readmission prevention
• Understanding of post-discharge patient needs and medical management strategies
• Ability to work full-time (five 8-hour days per week, Monday-Friday, 8:30 AM - 5:00 PM CST/MST/PST preferred), including one weekend shift per month
• Willingness and ability to obtain licensure in multiple states within 90 days of hire
• Active BLS certification (must maintain throughout employment)
• Strong teamwork skills and desire to work collaboratively in an interdisciplinary environment
• Comfort with adaptability and working in a fast-paced, evolving healthcare setting

Preferred:

• Experience in internal medicine, urgent care, emergency medicine, hospital medicine, post-acute care, or geriatrics
• Prior telehealth or virtual care delivery experience
• Experience managing transitional care patients and identifying needs for urgent intervention
• Clinical expertise managing acute and chronic disease exacerbations (CHF, diabetic emergencies, COPD, hypertensive emergencies)

How We Work With You

When you apply through Get A Job.ai, our recruiting team will review your qualifications and conduct an initial screening. If there's a strong match, we will submit your profile to our client for consideration. Please do not contact the employer directly—all communication and coordination will go through our team to ensure the best experience for you throughout the hiring process.

Pay

Pay via Get A Job.ai has not been specified for this role. Compensation details will be discussed during the interview process.

Equal Employment Opportunity: Get A Job.ai is committed to inclusive hiring practices and does not discriminate on the basis of race, color, religion, sex, national origin, disability, age, sexual orientation, veteran status, gender identity, or any other protected characteristic.