Advanced Practice Provider Float - Central Houston - Transitional Care Management

Job Description

Job Description

Benefits

• Paid Time Off & Paid Company Holidays
• Medical, Dental, Vision & Life Insurance
• Flexible Spending Account (FSA)
• 403(b) Retirement Plan with Company Match
• Short-Term & Long-Term Disability
• $0 Copay for Legacy Provider visits
• $0 Copay for prescriptions filled at Legacy Pharmacies
• Travel Insurance & Pet Insurance
• Subsidized Gym Membership
• And much more!

Apply today in less than 3 minutes using your phone, tablet, or computer!

Location: Legacy Montrose - 1415 California St. Houston, TX 77006 and Legacy Fifth Lyons- 3811 Lyons Ave. Houston, TX 77020

Nurse Practitioner - Transitional Care Management (TCM) - Job Overview

Schedule: Monday-Friday (8AM-5PM)

As a Advanced Practice Provider – Transitional Care Management, you will make a meaningful difference during the important days and weeks after a patient leaves a hospital, emergency department, skilled nursing facility, rehabilitation facility, or another acute or post-acute setting. Your advanced clinical expertise will help patients transition safely to outpatient care, support recovery, and ensure patients and families feel informed, supported, and connected.

You will build trusted relationships with patients and caregivers while providing timely assessments, medication reconciliation, individualized care planning, education, and coordination across the healthcare team. Through your work, you will strengthen continuity of care, help reduce avoidable readmissions and emergency department utilization, and advance value-based care outcomes in the community.

Make a Meaningful Difference

• Provide advanced clinical care during a critical transition in a patient’s healthcare journey.
• Help patients understand medications, follow-up plans, warning signs, and self-management needs.
• Identify clinical and social barriers that may affect recovery, including transportation, food insecurity, housing instability, behavioral health needs, and access to services.
• Support safer transitions and stronger connections among patients, caregivers, providers, specialists, community resources, and payers.

Collaborate, Connect, and Grow

• Partner with primary care providers, supervising or collaborating physicians, specialists, pharmacy, behavioral health, social services, care management, and other interdisciplinary team members.
• Participate in team meetings, huddles, case reviews, performance improvement activities, and value-based care initiatives.
• Bring your passion, clinical judgment, and communication skills to a team committed to helping patients thrive after discharge.
• Develop your expertise in transitional care management, quality improvement, readmission reduction, patient engagement, and value-based care.
• Help strengthen the outpatient healthcare ecosystem by ensuring patients receive timely follow-up and coordinated services.
• Support both individual patient recovery and broader community health outcomes through purposeful, patient-centered care.

Key Responsibilities

• Practice within the scope of licensure, organizational policies, and collaborative/supervisory agreements.
• Conduct timely post-discharge visits for patients recently discharged from hospitals, emergency departments, skilled nursing facilities, rehabilitation facilities, or other acute/post-acute settings.
• Review discharge summaries, inpatient records, diagnostic results, pending labs, discharge instructions, medication changes, and recommended follow-up care prior to or during the transitional care encounter.
• Perform comprehensive transitional care assessments, including evaluation of current symptoms, physical and functional status, chronic disease stability, psychosocial needs, social drivers of health, barriers to care, and risk for avoidable readmission or emergency department utilization.
• Complete medication reconciliation after discharge, identifying and addressing medication discrepancies, duplicate therapies, adherence barriers, affordability or access concerns, and patient understanding of medication changes.
• Diagnose and manage acute post-discharge needs and chronic conditions within scope of practice, including ordering or interpreting appropriate labs, diagnostics, medications, treatments, referrals, and follow-up services.
• Develop, update, and communicate individualized post-discharge care plans in collaboration with the patient, caregiver/family, primary care provider, supervising/collaborating physician, specialists, care management team, pharmacy, behavioral health, social services, and other interdisciplinary team members.
• Identify and address gaps in care following discharge, including needed appointments, labs, imaging, referrals, durable medical equipment, home health services, transportation, food insecurity, housing instability, behavioral health needs, and other social or clinical barriers.
• Provide patient and caregiver education regarding discharge instructions, red-flag symptoms, medication changes, disease-specific self-management, follow-up appointments, and when to seek urgent or emergency care.
• Coordinate timely follow-up with primary care providers, specialists, hospital partners, home health agencies, community resources, managed care organizations, and payers to support safe transitions and continuity of care.
• Escalate urgent clinical concerns, abnormal results, worsening symptoms, high-risk findings, or complex care needs to the supervising/collaborating physician, primary care provider, emergency services, or appropriate care team members as clinically indicated.
• Track and monitor assigned transitional care patients through the post-discharge period to support completion of follow-up appointments, ordered services, pending results, care plan interventions, and program closure requirements.
• Document all transitional care encounters, discharge review, medication reconciliation, clinical findings, diagnoses, care plan updates, patient education, referrals, outreach, and follow-up actions accurately and timely in the electronic health record.
• Participate in interdisciplinary care team meetings, huddles, case reviews, performance improvement activities, and reporting related to transitions of care, readmission reduction, emergency department utilization, quality metrics, patient engagement, and value-based care initiatives.
• Maintain current knowledge of transitional care management guidelines, payer and billing requirements, documentation expectations, quality measures, safety practices, infection control standards, and best practices for post-discharge care.
• Demonstrate respect and regard for the dignity of patients, families, visitors, and fellow employees; promote effective working relationships; follow required safety, exposure control, and organizational policies; and perform other duties as assigned.

Minimum Qualifications

• Current 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.

Required Years of Experience

• 2 years of experience is required.

Desirable Education and/or Experience

• Previous experience in an FQHC clinic setting is preferred,
• Transitional Care Management experience is preferred
• Value Based Care/Managed Care experience highly desirable

Required Knowledge, Skills, and/or Abilities

• Excellent 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

Desirable Knowledge, Skills, and/or Abilities

• Bilingual / Spanish fluency

About Legacy Community Health The largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has delivered affordable, high-quality care for nearly 40 years across 50+ clinics in Greater Houston and the Gulf Coast. Our mission — driving healthy change in our communities — guides everything we do, and it starts with our people.

Approachable & Collaborative — Leads with humility, values diverse perspectives, and builds trust through teamwork.

Driven & Committed — Takes initiative and goes the extra mile to improve patient outcomes and drive continuous improvement.

Thoughtful Communicators — Pairs clinical/technical skill with emotional intelligence, navigating complex situations with empathy and professionalism.

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