Texas Licensed Transitions of Care APP

To support a growing Transitions of Care program, the full-time Texas Licensed Transitions of Care APP will manage comprehensive post-discharge visits, conduct acute virtual care assessments, and collaborate with interdisciplinary teams to enhance patient outcomes in a fully remote setting. Key responsibilities Perform comprehensive initial post-discharge assessments and medication reconciliations for patients Independently assess and manage acute or worsening symptoms in medically complex patients during virtual visits Adjust and reinforce care plans across the 30-day post-discharge period, addressing evolving clinical needs and barriers Required qualifications 5+ years of direct patient care experience managing geriatric populations with complex chronic conditions Active and in good standing RN and APRN licenses or active PA license, with the ability to obtain licensure in required states within 90 days of hire Demonstrated experience in both acute management and longitudinal chronic disease management Ability to work full-time, five 8-hour days per week, preferably Monday-Friday Experience with telehealth platforms for patient visits