ADVANCED PRACTICE PROVIDER - #307497

Job Summary:

Reporting to the Chief Medical Officer, the Transition of Care (TOC) Advanced Practice Provider plays a critical role in bridging the gap between inpatient and outpatient care settings. This unique role is designed to support medically complex Medicare Advantage, Medi-Cal, and value-based care patients following hospitalization, emergency department visits, skilled nursing facility stays, rehabilitation admissions, and other high-risk transitions of care. The Advanced Practice Provider will collaborate closely with the Care Management team and partner with both inpatient and outpatient providers to ensure seamless transitions of care and optimal patient outcomes. The ideal candidate is highly independent, clinically experienced, and comfortable managing medically complex patients with significant chronic disease burdens.

Responsibilities:

Transitional Care Management

• Conduct post-discharge evaluations within 24–72 hours of hospital, SNF, LTAC, or rehabilitation discharge.
• Perform comprehensive medication reconciliation and management.
• Identify and address barriers to successful recovery and outpatient follow-up.
• Coordinate care with PCPs, specialists, hospitals, case managers, and community resources.
• Develop and implement individualized care plans focused on reducing readmissions and ED utilization.

Complex Medical Management

• Evaluate and manage patients with multiple chronic conditions and high-risk medication regimens.
• Monitor and adjust treatment plans within scope of practice.
• Provide bridge management until patients re-establish with their PCP or specialist.
• Review laboratory, imaging, and specialty consultation results.
• Escalate care appropriately when higher levels of intervention are required.

Specialty and Post-Acute Support

• Monitor patients receiving IV antibiotics and specialty therapies.
• Manage PICC lines and vascular access devices as appropriate.
• Perform wound assessments and dressing changes.
• Monitor weekly laboratory testing and treatment response.
• Coordinate home health, infusion, DME, and post-acute services.
• Educate patients and families regarding diagnoses, treatment plans, self-management strategies, and available resources.

Quality and Population Health

• Complete Annual Wellness Visits (AWVs).
• Address care gaps and preventive screening opportunities.
• Support RAF/HCC documentation and coding accuracy.
• Assist with quality initiatives, readmission reduction programs, and utilization management efforts.
• Participate in multidisciplinary case review meetings.

Care Coordination

• Collaborate closely with case management, social work, utilization management, and quality teams, to support continuity of care.
• Communicate with hospital discharge planners and community providers.
• Facilitate rapid specialty access and follow-up care.
• Support members with social determinants of health and access barriers.

Other Functions

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.
• Maintain IPA, Health Plan compliance standards.
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Competencies

• 8-10+ years of experience in primary care, hospital medicine, care management, or transitional care required.
• Prior Hospitalist, Critical Care, Emergency Medicine, Pulmonary, Cardiology, or Post-Acute Care experience required.
• Experience caring for Medicare Advantage or managed care populations preferred.
• Familiarity with value-based care models and population health management is preferred.
• Prior experience in transitional care, SNF, LTAC, home health, or care management settings preferred.
• Strong clinical assessment, communication, and care coordination skills preferred.
• Ability to work effectively within a multidisciplinary team environment.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking and analytical skills.
• Ability to solve complex-level problems with minimal supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers/patients.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need-to-know basis.
• Ability to exercise sound discretion and strict maintenance of confidentiality of all confidential and sensitive communications and information.
• Excellent attention to detail and ability to document information accurately.
• Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint, Visio) and Access is a plus.
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using e-mail applications.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• BA/BS degree in related field is required.
• Active and unrestricted Nurse Practitioner (NP) or Physician Assistant (PA) License in the State of California required.

Work Location & Travel

• The incumbent may travel up to 25% of the time.
• Primary work location is the Transitional Care Clinic (TCC) in the Sacramento region. Occasional travel to affiliated Vivant Health, LLC or partner FQHC sites may be required based on patient needs and program priorities.

Supervisor Responsibility

• This position may supervise several employees in the Transitional Care Clinic.

Work Environment

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.