Nurse Practitioner Transitional Care Service

Nurse Practitioner Transitional Care Service Full-Time | Remote Luminis Health is seeking an experienced Nurse Practitioner (NP) to join our Transitional Care Service in a fully remote position. The APP will provide virtual post-discharge care to medically complex patients transitioning from the hospital to home or skilled nursing facilities (SNFs). This role combines telehealth, clinical decision‑making, care coordination, patient education, and care management to help prevent avoidable readmissions and improve patient outcomes. Responsibilities: Conduct post‑discharge telephone and video assessments within 24-72 hours of hospital discharge. Provide telehealth follow‑up visits for high‑risk patients. Perform medication reconciliation and resolve medication discrepancies. Assess and manage acute clinical needs within APP scope of practice. Order, review, and act on labs, imaging, and other diagnostic testing as appropriate. Develop individualized care plans focused on preventing hospital readmissions. Coordinate care with PCPs, specialists, pharmacies, SNFs, home health agencies, and community resources. Serve as a clinical point of contact for patients and caregivers throughout the transitional period. Provide education regarding medications, disease management, warning signs, and follow‑up care. Coordinate appointments and services during the patient's 30-day transitional care period. Document patient encounters, care plans, communications, and outcomes in Epic. Participate in quality improvement and program development initiatives. Requirements: Current Maryland NP or PA license in good standing; additional state licensure as applicable. National certification through AANP/ANCC (NP) or NCCPA (PA-C). Minimum 2 years of experience in acute care, hospital medicine, transitional care, case management, or care coordination. Experience managing medically complex or high‑risk patients. Strong clinical judgment and independent decision‑making skills. Experience with medication reconciliation, discharge planning, and chronic disease management. Proficiency with Epic and telehealth platforms preferred. Excellent communication, organization, and time‑management skills. Ability to work independently and effectively collaborate with a multidisciplinary team. Remote Work: 100% remote position - no routine on‑site clinical work required. Patient care is delivered primarily through video visits and telephone‑based care. Must have a reliable internet connection and a private, HIPAA‑compliant workspace. Must be comfortable managing multiple patients and coordinating care independently in a virtual environment. 40 clinical hours per week, including flexible daytime, evening, and weekend hours as needed. Benefits: * Medical, Dental, Vision Insurance

• Paid Time Off & Paid Holidays
• Retirement Plan with Employer Match
• Tuition Assistance
• Wellness Programs
• Employee Referral Bonus
• Life Insurance, Disability & more

The Next Step Is Yours! Pursue your purpose and let's work together to support our commitment to providing high‑quality patient care for our communities. Luminis Health is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status. #J-18808-Ljbffr American Academy of Family Physicians