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Salary: USD 120,000 - 150,000 / annual
Devoted Health is seeking an experienced Advanced Practice Provider (Nurse Practitioner or Physician Assistant) to join its Transitions of Care (TOC) program. This role focuses on delivering virtual care during the critical 30-day window following patient hospitalization, with the goal of preventing readmissions through comprehensive, wrap-around care.
The position requires balancing two distinct clinical skill sets: approximately 70% of time is spent on comprehensive initial post-discharge assessments, and 30% on follow-up and acute/urgent symptom management. You will need both acute clinical judgment to recognize and manage medically complex, decompensating patients in real time, and longitudinal expertise to build and adjust whole-person chronic-care plans over the 30-day period.
Key responsibilities include:
- Conducting thorough post-discharge assessments covering medical conditions, medications, functional status, and psychosocial needs
- Performing complete medication reconciliation, identifying duplicates, contraindications, and optimizing guideline-directed therapy
- Placing appropriate orders (prescriptions, labs, imaging, referrals, home health, DME) and providing disease-specific education
- Independently assessing and managing new or worsening symptoms in complex patients, determining appropriate care levels and escalating when necessary
- Managing clinical trajectories across the 30-day window, adjusting care plans based on evolving clinical pictures and patient priorities
- Participating in interdisciplinary rounds with RN case managers, care coordinators, social workers, pharmacy, and external providers
- Contributing to team culture, clinical education, quality-improvement initiatives, and EHR feedback
- Supporting new clinical and organizational initiatives as the service evolves
The role is full-time, Monday-Friday, 8:30 AM–5:00 PM (CST/MST/PST preferred), with bilingual Spanish/English capability required.
Requirements:
- 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex comorbid conditions across acute and chronic presentations
- Demonstrated comfort across the continuum: acute management of chronic illness and longitudinal outpatient chronic-disease management
- Active, good-standing RN and APRN licenses OR active, good-standing Physician Assistant licenses
- Ability to work full-time, five 8-hour days per week
- Willingness and ability to obtain licensure in required states within 90 days of hire
- Bilingual proficiency in Spanish and English
Desired experience:
- Background in internal medicine, urgent care, emergency room, hospital medicine, post-acute medicine, or geriatrics
- Telehealth video platform experience
- Experience managing post-transition patients and identifying need for immediate interventions
- Experience managing acute/chronic disease exacerbations (CHF, diabetic emergencies, COPD, hypertensive emergencies)
- Strong team-player orientation with commitment to interdisciplinary collaboration
