Transitions of Care Advanced Practice Provider – NP, PA

Devoted Health

. Build and support the Transitions of Care program providing virtual care during the 30-day period after hospital discharge .

Posted 10/6/2026full-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 assessments, medication reconciliation, and virtual care delivery. Proficient in interdisciplinary collaboration and patient education to optimize health outcomes during the transitions of care.

Highest-signal resume keywords

5+ Years Direct Patient CareActive RN LicenseActive APRN LicenseExperience in TelehealthManagement of Chronic Illness

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medication ReconciliationChronic Disease ManagementAcute Care ManagementPatient AssessmentClinical Trajectory ManagementDisease-Specific EducationEHR ImprovementPost-Acute MedicineGeriatric CareTelehealth Visits

Soft Skills

CollaborationCommunicationPatient AdvocacyQuality ImprovementInterdisciplinary Teamwork

Certifications & Qualifications

RN LicenseAPRN LicensePhysician Assistant License

Industry Keywords

Transitions of CareChronic ConditionsGeriatricsAcute ManagementTelehealthInterdisciplinary RoundsHome HealthDME OrdersMedication TherapyPatient Escalation

About the role

Key responsibilities & impact

Build and support the Transitions of Care program providing virtual care during the 30-day period after hospital discharge
Perform comprehensive initial post-discharge visits, including medical, medication, functional, and psychosocial assessments
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 TOC visits for new or worsening symptoms
Assess, diagnose, manage, and escalate medically complex patients to the appropriate level of care
Manage each patient's clinical trajectory throughout the 30-day window
Participate in interdisciplinary TOC rounds for patients at highest risk of readmission
Collaborate with RN case managers, care coordinators, social work case managers, pharmacy, PCPs, specialists, and patients
Facilitate safe, open communication and support patient escalations
Assist with clinical education, quality-improvement projects, and pilots
Provide feedback to improve the homegrown EHR
Support evolving clinical and organizational initiatives in a fast-paced, dynamic build environment

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
Demonstrated 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 in-good-standing RN and APRN licenses, or active and in-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 visits over telehealth video platforms desired
Experience managing post-transitions patients and identifying the need for immediate interventions desired
Experience managing CHF exacerbations, diabetic emergencies, COPD exacerbations, and hypertensive emergencies 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
Bonus eligibility for all roles excluding Director and above
Parental leave program
401K program