Nurse Practitioner - Transitional Care Management (TCM)_El Paso, Texas

Job Overview

Sterling Health Solutions is seeking a dedicated Nurse Practitioner to join our Transitional Care Management (TCM) team. This remote, full-time position focuses on managing patients after discharge from hospitals, skilled nursing facilities, rehabilitation centers, and other care settings to improve outcomes, reduce readmissions, and ensure continuity of care.

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 with physicians, specialists, home health, and hospice providers.
• 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.