Nurse Practitioner - Transitional Care Management (TCM)

Nurse Practitioner - Transitional Care Management (TCM)Are you ready to make a meaningful difference in the lives of patients transitioning back to their everyday routines after a hospital stay? At Legacy Community Health, our Nurse Practitioners play a vital role in ensuring smooth transitions and promoting recovery. Join our family, where your passion for healthcare meets a supportive and collaborative team environment.Focus on post-discharge care to enhance patient recovery and reduce readmissionsCollaborate with interdisciplinary teams to ensure continuity of careEngage in personal and professional growth opportunitiesContribute to a mission-driven organization dedicated to community healthEnjoy a work-life balance that supports personal fulfillmentKey ResponsibilitiesPractice within the scope of licensure and organizational policiesConduct timely post-discharge visits for recently discharged patientsReview discharge summaries and related documents for comprehensive carePerform thorough transitional care assessmentsComplete medication reconciliation and address discrepanciesDiagnose and manage acute post-discharge needsDevelop and communicate individualized care plansIdentify and address gaps in post-discharge careProvide education to patients and caregivers on care instructionsCoordinate follow-up with healthcare providers and community resourcesEscalate urgent clinical concerns appropriatelyTrack and monitor patients through the post-discharge periodDocument all care encounters accurately in the electronic health recordParticipate in team meetings and performance improvement activitiesMaintain current knowledge of care management guidelines and best practicesDemonstrate respect and promote effective working relationshipsMinimum QualificationsCurrent license from the Texas Board of Nursing and completion of program at an accredited school.Provider shall obtain, maintain and participate in the Medicare and Medicaid Programs, workers compensation, other federal and state reimbursement programs, and the payment plan of any commercial insurer, health maintenance organization, preferred provider organization, accountable health plan, and other health benefit program requested by Legacy.2 years of experience is required.Previous experience in an FQHC clinic setting is preferredTransitional Care Management experience is preferredValue Based Care/Managed Care experience highly desirableExcellent communication skills and customer service skills.Must be able to manage multiple deadlines and prioritize.Demonstrated competency with an EHRS system.Ability to multitask in a fast-paced environment.Above average organizational skills.This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.Bilingual / Spanish fluency is desirable.About Legacy Community HealthAs the largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has been delivering comprehensive, high-quality, and affordable health care for nearly 40 years. With more than 50 clinics across the Greater Houston and Gulf Coast region, we continue to grow strategically and invest in our communities. By innovating how care is delivered, we've stayed at the forefront of connecting our communities to health—every day, in every way. At Legacy, we know our success is powered by our people. We're always looking for talented, passionate individuals who want more than a job—they want a meaningful career that makes a real impact. Explore our open positions and see if a career at Legacy is right for you.At Legacy Community Health, our mission—Driving healthy change in our communities—guides everything we do. To fulfill this mission, every team member is expected to embody the following core attributes in their daily work, regardless of role or department:Approachable & CollaborativeWe bring our expertise without ego. In a collaborative healthcare environment, humility fosters trust and teamwork. Our employees value diverse perspectives, seek input from others, and are unafraid to acknowledge when they need help. We stay grounded in our purpose: to serve patients and communities with compassion and humility.Driven & CommittedWe are driven by a deep commitment to excellence in patient care and organizational improvement. Our employees take initiative, embrace challenges, and go the extra mile to support our mission. Whether improving patient outcomes, streamlining processes, or stepping up in times of need, we are always striving to drive healthy change—within ourselves, our teams, and the communities we serve.Perceptive & Thoughtful CommunicatorsWe value emotional intelligence as much as clinical or technical skill. Our team members demonstrate sound judgment, cultural sensitivity, and the ability to navigate complex situations with empathy and professionalism. They communicate clearly and respectfully with patients, families, and colleagues, building trust and fostering a safe, inclusive environment for all.