Bilingual (Spanish/English) Transitions of Care Advanced Practice Provider

Job Description

Schedule

This is a full-time, 5-day, 8-hour position (8:30 AM – 5:00 PM CST/MST/PST). Candidates must be able to consistently work within Central (CST), Mountain (MST), or Pacific (PST) time zone hours.

A bit about this role

Our Devoted Medical Transitions of Care (TOC) Advanced Practice Provider (APP) roles include both Nurse Practitioners (APRNs) and Physician Assistants (PAs) — candidates for both will be considered. This is an opportunity for an experienced APP to help build the TOC Program. The TOC program provides virtual care during the 30-day window after a patient is discharged from a hospitalization. Our goal is to prevent readmissions by delivering exceptional, comprehensive, wrap-around care during this high-risk period.

The team is highly interdisciplinary — care coordinators, nurse case managers, social workers, APPs, and physicians collaborating together.

This role demands two distinct skill sets in one provider. Roughly 70% of your time is spent on comprehensive initial post-discharge visits, and 30% on follow-up and acute/urgent symptom visits. That means you need the acute clinical judgment to recognize and manage a decompensating, medically complex patient in real time, and the longitudinal depth to build and adjust a whole-person, complex chronic-care plan over 30 days .

You should be equally comfortable deciding whether a patient needs an immediate intervention today and managing the slower arc of their chronic disease across the continuum. You'll also help build the program itself — shaping team culture, fostering safe and open communication, contributing to quality-improvement work, and giving feedback on our homegrown EHR as we grow.

Responsibilities and impact will include:

• Perform comprehensive initial TOC visits. Conduct a thorough post-discharge assessment of the patient's medical conditions, medications, functional status, and psychosocial needs. Complete a full post-discharge medication reconciliation — including identifying duplicate, inappropriate, or contraindicated therapy and optimizing guideline-directed medical therapy. Place appropriate orders (prescriptions, labs, imaging, referrals, home health, DME), provide disease-specific education, and communicate clear contingency plans and red flags for worsening symptoms.
• Perform acute / virtual urgent-care TOC visits. Independently assess, diagnose, and manage new or worsening symptoms in medically complex patients, determine the appropriate level of care, and escalate when needed — with a clear bias to action.
• Manage the clinical trajectory across the 30-day window. Reinforce and adjust each patient's plan of care in response to their evolving clinical picture, their priorities, and the barriers they face — including chronic disease management, symptom management, and timely changes to the medical regimen.
• Participate in interdisciplinary TOC rounds to discuss patients at highest risk of readmission, and collaborate closely with RN case managers, care coordinators, social work case managers, pharmacy, and patients' PCPs and specialists.
• Enhance team culture by facilitating safe, open communication across roles and supporting clear patient escalations.
• Assist with clinical education of the broader team, participate in quality-improvement projects and pilots, and provide feedback to improve our EHR.
• Embrace a build environment. As our service needs evolve, this role may expand to support new clinical and organizational initiatives. We seek people who are adaptable, eager to learn, and comfortable in a fast-paced, dynamic setting where change is constant.
• Required skills and experience
• 5+ years of direct patient care managing primarily geriatric populations with multiple chronic, complex, comorbid conditions — across both acute and chronic presentations.
• Demonstrated comfort across the continuum: acute management of chronic illness and longitudinal outpatient chronic-disease management, with a strong understanding of how the two connect.
• Strong, independent clinical decision-making and bias to action in a virtual setting — comfortable being the clinician who recognizes deterioration and decides the next best step.
• Proficiency with complex medication reconciliation and guideline-directed medical therapy , especially for heart failure, COPD, diabetes, atrial fibrillation/anticoagulation, and hypertension — including recognizing duplicate, inappropriate, or contraindicated medications and adjusting regimens safely.
• Comfort diagnosing, managing, and monitoring decompensating patients with common high-readmission conditions such as heart failure, COPD, diabetes, hypertension, pneumonia, cellulitis, and urinary tract infections.

Salary Range:   $120,000-$150,000/year plus performance based bonus paid out quarterly or annually ($10K-$20K) for a total comp range of $130,000-$170,000/year.

Employer-sponsored health insurance and dental and vision plan with low or no premium

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. 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 will 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.

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!

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.