Transitions of Care Advanced Practice Provider

Devoted Health

Transitions of Care Advanced Practice Provider delivering virtual medical care to older adults post-discharge. Collaborating with interdisciplinary teams to manage complex chronic conditions and enhance patient outcomes.

Posted 6/25/2026full-timeRemote • Arizona, Florida, Ohio, Texas • 🇺🇸 United StatesMid-LevelSenior💰 $120,000 - $150,000 per yearWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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.
Ability to work the full-time 5-day, 8-hour schedule (Monday-Friday 8:30 AM – 5:00 PM within CST/PST/MST hours).
A strong, collaborative team player who thrives in an interdisciplinary environment.

Benefits

Comp & perks

Employer-sponsored health insurance and 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....

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medication reconciliationchronic disease managementacute care managementclinical decision-makingsymptom managementpatient assessmentdisease-specific educationguideline-directed medical therapydiagnosis of complex conditionsmonitoring of high-readmission conditions

Soft Skills

collaborationcommunicationadaptabilityindependenceteamworkbias to actioninterdisciplinary collaborationclinical educationproblem-solvingfeedback provision