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 readmissions
• Collaborate with interdisciplinary teams to ensure continuity of care
• Engage in personal and professional growth opportunities
• Contribute to a mission-driven organization dedicated to community health
• Enjoy a work-life balance that supports personal fulfillment

Key Responsibilities

• Practice within the scope of licensure and organizational policies
• Conduct timely post-discharge visits for recently discharged patients
• Review discharge summaries and related documents for comprehensive care
• Perform thorough transitional care assessments
• Complete medication reconciliation and address discrepancies
• Diagnose and manage acute post-discharge needs
• Develop and communicate individualized care plans
• Identify and address gaps in post-discharge care
• Provide education to patients and caregivers on care instructions
• Coordinate follow-up with healthcare providers and community resources
• Escalate urgent clinical concerns appropriately
• Track and monitor patients through the post-discharge period
• Document all care encounters accurately in the electronic health record
• Participate in team meetings and performance improvement activities
• Maintain current knowledge of care management guidelines and best practices
• Demonstrate respect and promote effective working relationships

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.
• 2 years of experience is required.
• Previous experience in an FQHC clinic setting is preferred
• Transitional Care Management experience is preferred
• Value Based Care/Managed Care experience highly desirable
• 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.
• Bilingual / Spanish fluency is desirable.

About Legacy Community Health

As 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 healthevery 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 jobthey 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 missionDriving healthy change in our communitiesguides 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 & Collaborative

We 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 & Committed

We 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 changewithin ourselves, our teams, and the communities we serve.

Perceptive & Thoughtful Communicators

We 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.