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Transitions of Care Nurse Practitioner

Devoted Health

Devoted Health

United States · Remote
Posted on Sep 4, 2024

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

A bit more 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.

Responsibilities 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.

  • Perform acute symptom TOC 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 a daily 30 minute interdisciplinary meeting discussing patients who are at highest risk of readmission due to worsening clinical symptoms.

  • 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.

Attributes to Success:

  • Skilled nurse practitioner with comprehensive knowledge of post-transitions care, acute conditions, diagnostics, and treatments.

  • Adept ordering of appropriate diagnostic testing , quality of care interventions, and completing a comprehensive diagnosis review.

  • Thorough and thoughtful in addressing the needs of patients.

  • Deeply empathetic and humanistic, and willing to care for patients like family.

  • Energized by a fast-paced, rapidly growing organization, with the agility and resilience to embrace change and rapid cycles of quality improvement

  • A growth mindset that enjoys learning new things

  • Willing to embrace new technologies that are being developed within the organization

  • Assumption of positive intent of others

  • Desire to solve problems, improve clinical medicine, and drive innovation in transitions of care

Required skills and experience:

  • Bilingual in English and Spanish

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

  • 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, urgent care, emergency room, hospital medicine, post-acute medicine, and/or geriatrics.

  • Experience performing visits over telehealth video platforms
    Experience in managing post-transitions patients and being able to identify the need for immediate interventions.

  • Experience in managing acute/chronic disease exacerbations including CHF exacerbations, diabetic emergencies, COPD exacerbations and hypertensive emergencies.

Licensure and Certification

  • Role licensure and good standing is required in existing or future Devoted states. Able and willing to get licensed in required states within 90 days of hire

  • RN and APRN licenses are active and in good standing

  • Active BLS certification at time of hire and must maintain while employed at Devoted Medical

Salary Range: $113,000 - $131,000 annually

#LI-REMOTE

Our ranges are purposefully broad to allow for growth within the role over time. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered may depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

  • Employer sponsored health, 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; Commission eligibility for Sales roles

  • Parental leave program

  • 401K program

  • And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.