Nurse Practitioner - Transitional Care Management (TCM)_Austin, Texas

Key Responsibilities

• Conduct Transitional Care Management visits and patient assessments.
• Review discharge summaries, medications, and treatment plans.
• Perform medication reconciliation and identify care gaps.
• Develop individualized care plans and monitor patient progress.
• Career coordination and ensure continuity of care.
• Educate patients and caregivers regarding treatment plans and follow-up care.
• Document encounters accurately within eClinicalWorks (eCW).
• Support quality, compliance, and patient outcome initiatives.

Qualifications

• Active and unrestricted Texas Nurse Practitioner license.
• National Board Certification.
• DEA license or ability to obtain.
• Strong clinical assessment, communication, and documentation skills.
• Ability to work independently in a remote environment.

Preferred Qualifications

• Experience in Transitional Care Management (TCM).
• Primary Care, Internal Medicine, Home Health, Hospice, or Care Coordination experience.
• Experience with eClinicalWorks (eCW).
• Bilingual (English/Spanish) preferred but not required.