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.
• 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.
• 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.
• Proficiency with complex medication reconciliation and guideline-directed medical therapy, especially for heart failure, COPD, diabetes, atrial fibrillation/anticoagulation, and hypertension — including recognizing duplicate, inappropriate, or contraindicated medications and adjusting regimens safely.
• Ability to work the full-time 5-day, 8-hour schedule (Monday-Friday 8:30 AM – 5:00 PM within CST/PST/MST hours).
• A strong, collaborative team player who thrives in an interdisciplinary environment.
• 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.
• Experience managing acute and chronic disease exacerbations, including CHF exacerbations, COPD exacerbations, diabetic emergencies, and hypertensive emergencies, and identifying the need for immediate intervention.
• Experience performing visits over telehealth video platforms.
• Experience working with frail, complex, or vulnerable populations, including in the skilled nursing facility (SNF) setting.
• A continuous-improvement mentality, can-do attitude, and the ability to adapt quickly to new workflows and changes.

Qualifications

• For Nurse Practitioners: active and in-good-standing RN and APRN licenses.
• For Physician Assistants: an active and in-good-standing Physician Assistant license.

Skills

• 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.
• Experience managing acute and chronic disease exacerbations, including CHF exacerbations, COPD exacerbations, diabetic emergencies, and hypertensive emergencies, and identifying the need for immediate intervention.
• Experience performing visits over telehealth video platforms.
• Experience working with frail, complex, or vulnerable populations, including in the skilled nursing facility (SNF) setting.
• A continuous-improvement mentality, can-do attitude, and the ability to adapt quickly to new workflows and changes.

Benefits

Employer-sponsored health, 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...

Pay

$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.