Transitions of Care Advanced Practice Provider (NP or PA)

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.

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'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

• 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 elevate when needed — with a clear bias to action.
• 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.
• Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR.

Qualifications

• 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions — across both acute and chronic presentations.
• ~ Ability to work full-time, five-8 hour days/week (Monday-Friday, 8:30 AM - 5:00 PM; RN and APRN licenses are active and in good standing or Physician Assistant licenses are active and in good standing. Experience in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics.
• Experience performing visits over telehealth video platforms.
• Experience in managing acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations and hypertensive emergencies.
• Strong team player, with a desire to work in an interdisciplinary team to provide the best care to patients.

Benefits & Compensation

• 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
• The 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. Employer sponsored health, dental and vision plan with low or no premium
• ~ Stock options for all employees
• ~ Bonus eligibility for all roles excluding Director and above; Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

We value diversity and collaboration. 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.