Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider

About the role

Roughly 70% of your time is spent on comprehensive initial post-discharge visits, and 30% on follow-up and acute/urgent symptom visits. This role demands two distinct skill sets in one provider.

Responsibilities

• Perform comprehensive initial TOC visits.
  • Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs.
    • Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy.
      • Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms.
• Conduct acute / virtual urgent-care TOC visits.
  • Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action.
• Manage the clinical trajectory across the 30-day window.
  • Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen.
• Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists.

Requirements

• 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions — across both acute and chronic presentations.

Qualifications

• Demonstrated comfort across the continuum: acute management of chronic illness and longitudinal outpatient chronic-disease management, with a strong understanding of how the two connect.

Skills and Experience

• Strong, independent clinical decision-making and bias to action in a virtual setting — comfortable being the clinician who recognizes deterioration and decides the next best step.

Desired Skills and Experience

• Experience in internal medicine, hospital medicine, post-acute/SNF medicine, urgent care or emergency medicine, geriatrics, palliative care, and/or primary care with a strong chronic disease management focus.

Pay and Benefits

Salary Range: $120,000-$150,000/year plus performance based bonus paid out quarterly or annually ($10K-$20K) for a total comp range of $130,000-$170,000/year.

Employer-sponsored health insurance and dental and vision plan with low or no premium

Generous paid time off

$100 monthly mobile or internet stipend

Stock options for all employees

Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

Parental leave program

401K program

And more....