Job Description
Job Description Schedule This is a full-time, 5-day, 8-hour position (8:30 AM – 5:00 PM CST/MST/PST). Candidates must be able to consistently work within Central (CST), Mountain (MST), or Pacific (PST) time zone hours. A bit about this role Our Devoted Medical Transitions of Care (TOC) Advanced Practice Provider (APP) roles include both Nurse Practitioners (APRNs) and Physician Assistants (PAs) — candidates for both will be considered. This is an opportunity for an experienced APP to help build the TOC Program. The TOC program provides virtual care during the 30-day window after a patient is discharged from a hospitalization. Our goal is to prevent readmissions by delivering exceptional, comprehensive, wrap-around care during this high-risk period. The team is highly interdisciplinary — care coordinators, nurse case managers, social workers, APPs, and physicians collaborating together. This role demands two distinct skill sets in one provider. Roughly 70% of your time is spent on comprehensive initial post-discharge visits, and 30% on follow-up and acute/urgent symptom visits. That means you need the acute clinical judgment to recognize and manage a decompensating, medically complex patient in real time, and the longitudinal depth to build and adjust a whole-person, complex chronic-care plan over 30 days . You should be equally comfortable deciding whether a patient needs an immediate intervention today and managing the slower arc of their chronic disease across the continuum. You'll also help build the program itself — shaping team culture, fostering safe and open communication, contributing to quality-improvement work, and giving feedback on our homegrown EHR as we grow. Responsibilities and impact will include: Perform comprehensive initial TOC visits. Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. Complete a full post-discharge medication reconciliation — including identif
