Nurse Practitioner, Care Transitions

Role Overview Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The Nurse Practitioner, Care Transitions is the clinical anchor of the post-discharge episode - the billing provider for Avail Health's 30-day Transitional Care Management (TCM) program. You’ll deliver comprehensive post-discharge visits, primarily via virtual care, within 1–14 days of hospital discharge. Your work includes clinical assessment, medication reconciliation, risk stratification, and moderate- to high-complexity medical decision-making to support safe transitions and reduce avoidable readmissions. You’ll work within a purpose-built interdisciplinary team alongside an RN Care Manager, SW Care Manager, and Care Coordinators, supported by HIE integrations and an ambient AI scribe. When patients can’t be seen virtually, you’ll conduct mobile in-person visits across the Montgomery County region. This is a founding clinical role. The program infrastructure is being built around it. What You’ll Own Clinical delivery of the 30-day TCM episode - from post-discharge visit through transition to longitudinal care Billing compliance and documentation accuracy for all TCM encounters Clinical decision-making for a complex, high-risk Medicare patient panel with medical, behavioral health, and psychosocial needs What You’ll Do Serve as the billing provider for Avail Health's TCM episode, conducting comprehensive post-discharge visits within 1–14 days of hospital or post-acute discharge Perform clinical assessment, medication reconciliation, risk stratification, and moderate- to high-complexity medical decision-making Identify gaps in care, initiate diagnostic or treatment interventions, and coordinate with specialists and community resources to support safe transitions Participate in daily team huddles with the RN Manager, RN Care Manager, SW Care Manager, and Care Coordinators for panel review, risk escalation, and coordinated care planning Use an ambient AI scribe to support real-time documentation; complete all TCM billing elements accurately and in compliance with CMS requirements Support continuity of care for high-risk patients throughout and beyond the TCM episode, including warm handoffs into longitudinal care management programs Contribute frontline clinical feedback to support workflow refinement, protocol development, and program improvement as the program scales What Success Looks Like TCM visits completed within CMS-required windows at or above program targets 30-day readmission rate for enrolled patients at or below program benchmarks Documentation and billing accuracy consistently meeting compliance standards Complex patients risk-stratified and connected to the right interdisciplinary resources within the TCM episode Clinical protocols and standing orders developed and refined in partnership with program leadership What You Bring Required: MSN or DNP from an accredited program Active, unrestricted Maryland NP license in good standing Dual board certification: AGPCNP-BC + PMHNP-BC, or FNP-C/FNP-BC + PMHNP-BC Minimum 3 years of independent NP clinical experience in both psychiatric/mental health and adult primary or acute care; geriatric experience strongly preferred Active Maryland DEA registration, or eligibility and willingness to obtain prior to start Experience with post-hospital transitions of care, discharge planning, or complex care coordination Experience in mobile care settings (home health, hospice, house calls, or similar) Comfort operating in a virtual-first, technology-enabled environment with evolving workflows Valid driver's license, reliable transportation, and active automobile insurance Preferred: Experience in TCM, hospital readmission reduction, longitudinal care management, complex case management, population health, or interdisciplinary Medicare programs Familiarity with CMS TCM billing and documentation requirements Experience with Medicare-aged populations with complex comorbidities, frailty, polypharmacy, behavioral health conditions, or dementia-related needs Familiarity with telehealth platforms, HIE systems, ambient AI documentation tools, or e-consult platforms Schedule and Work Style Work Type: Hybrid — primarily virtual with mobile in-person visits as needed. Schedule: Monday–Friday, 8:00 AM – 5:00 PM ET. Travel: Mobile in-person visits across Montgomery County, MD when patients cannot be seen virtually; must reside within commuting distance of Rockville. Autonomy: High - serves as the clinical decision-maker for a complex patient panel with interdisciplinary team support. 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) provided 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 #J-18808-Ljbffr