Bilingual (Spanish) Transitions of Care Nurse Practitioner

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.  And we've just started. So join us on this mission!

Job Description

This role is a fully remote position.

You must be willing to work a Monday through Friday schedule, including one weekend shift per month.

A bit about this role: 

This position represents an amazing opportunity for a Nurse Practitioner (APRN) to help build Devoted Medical’s Transitions of Care (TOC) Program. The TOC program provides virtual care in the 30 day window after a patient is discharged from the acute setting (hospital or skilled nursing facility). The clinical team is highly interdisciplinary and composed of coordinators, guides, nurse case managers, nurse practitioners, and a medical director. The program’s goal is to prevent readmissions by providing exceptional, comprehensive wrap-around care in the post-discharge period. 

The TOC NP will provide virtual clinical care for a wide range of diseases and across a wide spectrum of acuity. This position will require the ability to conduct a comprehensive post-discharge medical assessment, develop individualized care plans, and provide disease-specific clinical education regarding management and red flags. The TOC NP must also be comfortable diagnosing, managing, and monitoring decompensating patients with common readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections. 

The role will require significant interdisciplinary collaboration with nurse case managers, clinical guides, and clinical coordinators, all aimed at providing the best post-discharge care for patients possible. The TOC NP will also help enhance the team culture of the program by fostering a safe environment for team communication and patient escalations. 

Your Responsibilities and Impact will include:

• Perform initial TOC visits. These visits include comprehensive post-discharge assessment of patients’ medical conditions, medications, functional status, and psychosocial needs. Additional requirements include completing a post-discharge medication reconciliation, placing appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), providing appropriate disease education, communicating contingency plans for worsening symptoms, and comprehensively assessing a patient’s medical conditions.  

• Perform acute symptom TOC / virtual urgent care visits. These are visits focused on addressing a patient’s acute need or new symptom. During these visits, NPs will be required to diagnose and manage the patient, and ensure they receive the appropriate level of care.

• Participate in interdisciplinary TOC rounds. This is an interdisciplinary meeting to discuss patients who are at highest risk of readmission. 

• Work in an interdisciplinary fashion with RNs, LPNs, and clinical coordinators.

• Assist with the clinical education of the overall team.

• Enhance team culture by facilitating safe, open communication across team roles

• Utilize our home grown electronic health information system for visits while also providing feedback on how to improve the interface. 

• Regularly participate in quality improvement projects and pilots.

Required skills and experience:

• At least 3 years of experience in hospital, post-hospital setting, or primary care setting, with clear understanding of common hospital discharge diagnoses, post-discharge needs, and the medical management required to avoid readmissions. 

• Bilingual in English and Spanish.

• Must be willing to work five 8-hour shifts (Monday-Friday), including one weekend shift per month.

• Strong team player, with a desire to work in an interdisciplinary team to provide the best care to patients.

Desired skills and experience:

• Experience in internal medicine, urge