Nurse Practitioner, Care Transitions (Dual Board-Certified)

Role Overview
You'll serve as the billing provider for Avail Health's 30-day TCM episode - conducting comprehensive post-discharge visits, primarily virtual, within 1-14 days of hospital discharge. Your patients are Medicare-age adults navigating complex medical and behavioral health needs after a hospitalization. Your job is to assess, stabilize, and connect them to the right next level of care before the window closes.
You'll work inside a tight interdisciplinary team (RN Care Manager, SW Care Manager, Care Coordinator) supported by HIE integrations and an ambient AI scribe. The workflow overhead is handled. You focus on the clinical judgment.
This is a founding role in a newly launching program. You'll help build the model, not just run it. What You'll Own
• The TCM billing encounter and CMS compliance for each patient's 30-day episode
• Medication reconciliation decisions and prescription authority within your scope
• Clinical risk stratification at the point of the TCM visit and escalation when patients need a higher level of care What You'll Do
• Conduct virtual TCM visits within 1-14 days of discharge; conduct mobile in-person visits when patients can't be seen remotely
• Perform medication reconciliation and document moderate- to high-complexity MDM at the time of each TCM encounter
• Apply dual-specialty (medical + behavioral health) judgment to assess complexity and initiate the right post-discharge intervention
• Facilitate warm handoffs into behavioral health, dementia care management, and chronic disease programs for qualifying patients
• Participate in daily team huddles to review the panel, flag high-risk cases, and align on care priorities
• Complete visit documentation same-day using an ambient AI scribe; ensure full CMS billing compliance What Success Looks Like
• TCM visits completed within the 1-14 day post-discharge window for 95%+ of assigned patients
• Medication reconciliation documented at the time of the TCM visit for 100% of assigned patients
• 30-day readmission rate for assigned panel at or below program benchmarks
• Warm handoffs initiated for all clinically eligible patients within the TCM episode
• Clinical documentation completed same-day with billing elements accurate and audit-ready What You'll Bring
Required:
• Active Maryland NP license; MSN or DNP from an accredited program
• Dual board certification: AGPCNP-BC + PMHNP-BC, or FNP-C/FNP-BC + PMHNP-BC
• 3+ years of independent NP experience in both psychiatric/mental health and adult primary or acute care; geriatric experience strongly preferred
• Maryland DEA registration (or eligibility to obtain prior to start)
• Experience in post-hospital transitions, mobile care (home health, hospice, house calls), or complex care coordination
• Valid driver's license and reliable transportation

Preferred:
• Familiarity with TCM billing, CMS documentation standards, or interdisciplinary Medicare programs
• Experience with frailty, polypharmacy, dementia, or complex behavioral health presentations in older adults
• Familiarity with telehealth platforms, HIE systems, or ambient AI documentation tools Schedule and Work Style
Work Type: Hybrid - primarily remote/virtual with mobile field visits as needed
Schedule: Monday-Friday, 8:00 AM - 5:00 PM ET; occasional on-call participation as program scales
Travel: Field visits across Montgomery County, MD; must reside within commuting distance of Rockville
Autonomy: High - NP-level clinical independence with daily team touchpoints for panel review and escalations Compensation and Perks
Salary Range: $137,500 - $172,500 annually, commensurate with experience
Key Benefits:
• Medical, dental, and vision insurance
• HSA | 401(k) with employer match
• 15 days PTO | 8 + 1 floating holidays
• Professional liability and malpractice insurance ($1M/$3M)
• All devices for clinical and technology-related activities provided About Avail Health
Avail Health is a Nurse Practitioner-founded organization delivering mobile and virtual care to Medicare-age patients. We combine technology, operational rigor, and clinical excellence to improve outcomes for complex populations. For more visit

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