Bilingual Transitions of Care Advanced Practice Provider, NP/PA

Devoted Health

. Perform comprehensive initial transitions-of-care visits after hospitalization .

Posted 10/9/2026full-timeRemote • United StatesMid-LevelSenior💰 $120,000 - $150,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing complex geriatric patients through comprehensive transitions-of-care, including medication reconciliation, acute management of chronic illnesses, and interdisciplinary collaboration. Proficient in telehealth practices and committed to enhancing clinical education and quality improvement initiatives.

Highest-signal resume keywords

Geriatric Patient ManagementMedication ReconciliationTelehealth ExperienceInterdisciplinary Team CollaborationChronic Disease Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Acute Management of Chronic IllnessClinical AssessmentSymptom Diagnosis and ManagementCare Level DeterminationPatient EducationEHR ImprovementDME OrderingLab and Imaging OrdersReferral ManagementQuality Improvement Projects

Soft Skills

Interdisciplinary TeamworkCommunication SkillsPatient AdvocacyProblem-SolvingCultural Competence

Tools & Technologies

EHR SystemsTelehealth Platforms

Certifications & Qualifications

Active RN LicenseActive APRN LicenseActive Physician Assistant License

Industry Keywords

Transitions of CarePost-Acute MedicineChronic Disease ManagementGeriatricsInternal MedicineUrgent CareEmergency RoomHospital Medicine

About the role

Key responsibilities & impact

Perform comprehensive initial transitions-of-care visits after hospitalization
Assess medical conditions, medications, functional status, and psychosocial needs
Complete medication reconciliation and optimize guideline-directed medical therapy
Place prescriptions, lab, imaging, referral, home-health, and DME orders
Provide disease-specific education and contingency plans for worsening symptoms
Perform acute and virtual urgent-care transitions-of-care visits
Assess, diagnose, and manage new or worsening symptoms in medically complex patients
Determine appropriate care levels and escalate when needed
Manage each patient's clinical trajectory across the 30-day post-discharge window
Participate in interdisciplinary TOC rounds for high-readmission-risk patients
Collaborate with case managers, care coordinators, social work, pharmacy, PCPs, and specialists
Facilitate safe, open communication and clear patient escalations
Support clinical education, quality-improvement projects, pilots, and EHR improvements
Help build the TOC program, team culture, and evolving clinical initiatives

Requirements

What you’ll need

5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions across acute and chronic presentations
Comfort with acute management of chronic illness and longitudinal outpatient chronic-disease management
Ability to work full-time, five 8-hour days per week, Monday-Friday, 8:30 AM-5:00 PM; CST/MST/PST preferred
Active and good-standing RN and APRN licenses, or active and good-standing Physician Assistant license
Role licensure and good standing required in existing or future Devoted states
Able and willing to obtain licenses in required states within 90 days of hire
Experience in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics desired
Experience performing telehealth video visits desired
Experience managing post-transition patients and identifying the need for immediate interventions desired
Experience managing CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive emergencies desired
Strong interdisciplinary teamwork skills desired

Benefits

Comp & perks

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
Performance-based bonus eligibility
Parental leave program
401K program