Transitions of Care Advanced Practice Provider

Job DescriptionScheduleThis 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 roleOur 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 identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms.Perform acute / virtual urgent-care TOC visits. Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action.Manage the clinical trajectory across the 30-day window. Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen.Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists.Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations.Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR.Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives. We seek people who are adaptable, eager to learn, and comfortable in a fast-paced, dynamic setting where change is constant.Required skills and experience5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions — across both acute and chronic presentations.Demonstrated comfort across the continuum: acute management of chronic illness and longitudinal outpatient chronic-disease management, with a strong understanding of how the two connect.Strong, independent clinical decision-making and bias to action in a virtual setting — comfortable being the clinician who recognizes deterioration and decides the next best step.Proficiency with complex medication reconciliation and guideline-directed medical therapy, especially for heart failure, COPD, diabetes, atrial fibrillation/anticoagulation, and hypertension — including recognizing duplicate, inappropriate, or contraindicated medications and adjusting regimens safely.Comfort diagnosing, managing, and monitoring decompensating patients with common high-readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.Ability to work the full-time 5-day, 8-hour schedule (Monday-Friday 8:30 AM – 5:00 PM within CST/PST/MST hours).A strong, collaborative team player who thrives in an interdisciplinary environment.Desired skills and experienceExperience in internal medicine, hospital medicine, post-acute/SNF medicine, urgent care or emergency medicine, geriatrics, palliative care, and/or primary care with a strong chronic disease management focus.Experience managing acute and chronic disease exacerbations, including CHF exacerbations, COPD exacerbations, diabetic emergencies, and hypertensive emergencies, and identifying the need for immediate intervention.Experience performing visits over telehealth video platforms.Experience working with frail, complex, or vulnerable populations, including in the skilled nursing facility (SNF) setting.A continuous-improvement mentality, can-do attitude, and the ability to adapt quickly to new workflows and changes. Licensure and certificationFor Nurse Practitioners: active and in-good-standing RN and APRN licenses. For Physician Assistants: an active and in-good-standing Physician Assistant license.Licensure and good standing required in existing or future Devoted states; able and willing to obtain required state licenses within 60-90 days of hire. We are Licensure in FL TX AZ OH and/or GA required to start. Salary Range: $120,000-$150,000/year plus performance based bonus paid out quarterly or annually ($10K-$20K) for a total comp range of $130,000-$170,000/year. Employer-sponsored health insurance and dental and vision plan with low or no premium#LI-RemoteThe pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.Our Total Rewards package includes:Employer sponsored health, dental and vision plan with low or no premiumGenerous paid time off$100 monthly mobile or internet stipendStock options for all employeesBonus eligibility for all roles excluding Director and above; Commission eligibility for Sales rolesParental leave program401K programAnd more....*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.SummaryLocation: Remote USA; Fully Remote - Texas; Fully Remote - Arizona; Fully Remote - Ohio; Fully Remote - Florida; Fully Remote - California; Fully Remote - Georgia; Fully Remote - New MexicoType: Full time