Transitional Care Nurse Practitioner opening in Philadelphia, PA

Details/Responsibilities:

• Full-time, Mon - Fri, 8am-5pm
• Deliver high-touch, high-quality care to the highest risk patients within their homes
• This role is supported by a scribe/medical assistant, nurse, social worker, and other resources.
• NPs make 6-7 visits daily in a defined territory and collaborate continuously with other team members for care coordination and all other needs.
• APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up.
• Provide post-discharge support according to defined pathways within the patient's home
• Develop care plans and individualize goals of care with patient, their families, and their providers
• Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
• Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
• Structure and prioritize scheduling based on clinical complexity for both new and routine patients
• Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
• Provide after-hours and weekend call support, shared with other in state providers
• Facilitate and conduct goals of care and advance care planning discussions with patients and families
• Assess and evaluate family / caregiver needs and limitations
• Teach patients, caregivers, and others about their health conditions
• Accurate and timely documentation of patient encounters in electronic medical records
• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
• Other duties, as assigned

Qualifications:

• Have an active, non-probationary state medical license, including US work authorization, if applicable
• 1+ years APN experience, preferably with a Medicare population
• Experience in home-based care (as RN or APP) preferred
• Flexibility to travel throughout service area
• Electronic Medical Record experience
• Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.

Compensation & Benefits:

• Competitive Salary
• Paid vacation, sick time, and investment/retirement 401K match options
• Health insurance, vision, and dental benefits
• Opportunities for leadership development and continuing education stipends
• New centers and flexible work environments
• Opportunities for high levels of responsibility and rapid advancement

The Community:

Experience life in a vibrant, historic city that perfectly balances rich cultural heritage with modern urban energy. This area boasts iconic architecture, world-class museums, diverse dining scenes, and thriving neighborhoods filled with charm and character. Residents enjoy easy access to expansive parks, waterfronts, and bustling markets, all while benefiting from a strong job market in education, healthcare, finance, and technology. Situated conveniently between major East Coast hubs, it’s just a short trip to New York City, Washington D.C., and even the beaches of New Jersey, making weekend getaways and career opportunities effortlessly accessible. Whether you crave the buzz of city life or cozy community vibes, this metropolitan gem offers a dynamic lifestyle that’s hard to beat.

APPLY NOW or TEXT Job #CMW231889 and email address to 636 - 628 - 2412.


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