Transitional Care Management & Internal Medicine Nurse Practitioner (NP)

Job Summary
We are seeking a dynamic and compassionate Transitional Care Management & Internal Medicine Nurse Practitioner (NP) to join our dedicated healthcare team. This role offers an exciting opportunity to provide comprehensive, patient-centered care across various settings, including post-acute, outpatient, and inpatient environments. You will be instrumental in coordinating care transitions, managing complex medical cases, and promoting optimal health outcomes for diverse patient populations. Your expertise will help bridge gaps in care, improve patient satisfaction, and support ongoing health management through innovative practices and collaborative teamwork.

Responsibilities

• Conduct thorough patient assessments, including vital signs, physical examinations, and detailed medical histories to inform diagnosis and treatment plans.
• Develop and implement individualized care plans for patients transitioning from hospital to home or other care settings, ensuring seamless continuity of care.
• Manage chronic conditions such as diabetes, hypertension, and heart disease by providing education, medication management, and lifestyle counseling.
• Collaborate closely with physicians, specialists, case managers, and community resources to coordinate post-discharge care and follow-up appointments.
• Utilize electronic health record (EHR) eClinicalWorks to document patient encounters accurately and efficiently while maintaining HIPAA compliance.
• Perform medication reconciliation
• Engage in telehealth consultations to extend access to care for remote or mobility-limited patients while ensuring high-quality clinical evaluations.

Skills

• Proven experience working with complex patient populations in settings such as hospital medicine, post-acute care, or skilled nursing facilities.
• Strong proficiency with EMR/EHR system ; familiarity with medical documentation standards is essential.
• Extensive knowledge of internal medicine principles combined with skills in acute pain management, infection control, and chronic disease management.
• Experience with telehealth platforms to provide remote patient assessments and follow-up care effectively.
• Familiarity with CPT coding, ICD-10 coding systems for accurate billing and documentation purposes.
• Excellent communication skills for patient education on topics like nutrition, memory care (including Alzheimer’s disease), hospice & palliative medicine, and behavioral health strategies.
• Ability to work collaboratively within multidisciplinary teams across various healthcare environments including assisted living facilities, nursing homes, hospitals (Level I & II trauma centers), ICUs (Intensive Care Units), emergency rooms, and outpatient clinics.

Pay: $55,510.37 - $66,851.20 per year

Benefits:

• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Professional development assistance
• Vision insurance

Application Question(s):

• Current Arizona licensure with prescriptive authority

License/Certification:

• AZ license or eligibility for licensure in the State of AZ (Required)

Work Location: In person