Nurse Practitioner - Transitions Medical Partners - Primary Care

The schedule for this role is Monday-Friday 8:30 am to 5:00 pm.

This role delivers direct patient care to individuals with acute, chronic, complex, and serious illness; supports continuity of care across settings; and collaborates closely with interdisciplinary teams. The Nurse Practitioner functions under the guidance of the Chief Medical Officer, Medical Director, referring physicians, and established plans of care, while practicing to the full scope of advanced practice nursing.

The position also supports provider, staff, and community education related to primary care, chronic disease management, pain and symptom management, serious illness communication, advanced care planning, and available services across the Transitions LifeCare continuum.

Responsibilities

Clinical Care – Primary Care

• Provide comprehensive primary care services, including health maintenance, preventive care, and management of acute and chronic medical conditions
• Perform patient assessments, physical examinations, and diagnostic evaluations
• Diagnose and manage common primary care conditions (e.g., hypertension, diabetes, COPD, CHF, dementia, depression, and other chronic illnesses)
• Order, review, and interpret diagnostic tests and laboratory studies
• Prescribe medications and therapeutic interventions consistent with scope of practice, collaborative agreements, and regulatory requirements
• Provide patient and caregiver education focused on disease management, health promotion, and self‑care
• Participate in on-call rotation schedule with MD / Medical Director and team

Palliative Care and Hospice Services

• Provide palliative care consultation and hospice visits in residential facilities, home settings, hospice inpatient facilities, and hospitals
• Deliver pain and symptom management interventions based on established hospice and palliative care guidelines and standards
• Conduct goals‑of‑care discussions, advance care planning, and shared decision‑making with patients and families
• Provide attending provider services for hospice patients when assigned
• Complete face‑to‑face visits to ensure compliance with Medicare/Medicaid hospice regulations
• Attend Interdisciplinary Group (IDG) meetings as appropriate

Care Coordination and Collaboration

• Collaborate with physicians, nurses, social workers, chaplains, care managers, and other interdisciplinary team members
• Coordinate transitions of care across inpatient, outpatient, home‑based, and residential settings
• Communicate effectively with referring providers, facility staff, and community partners to ensure continuity and quality of care

Documentation, Quality, and Education

• Document accurately and timely in the patient medical record in accordance with federal, state, regulatory, and agency requirements
• Assist with data collection, quality metrics, forms, and outcome evaluation tools for primary care, palliative care, and hospice programs
• Work with the Chief Medical Officer and Associate Medical Director to educate hospital staff, residential facility staff, and community physicians on:
  • Primary care integration
  • Chronic disease management
  • Palliative care principles
  • Pain and symptom management
  • End‑of‑life communication
  • Available Transitions LifeCare programs
• Participate in on‑call rotation as required by contract agreement
• Perform other duties as assigned by supervisor

Expectations

• Demonstrate professionalism, compassion, respect, teamwork, and accountability in all interactions
• Adhere to all Transitions LifeCare policies, procedures, and organizational guidelines
• Deliver care in accordance with ACHC Standards and Medicare Conditions of Participation as applicable
• Comply with all state and federal laws, regulations, and professional standards within defined scope of practice
• Communicate concerns, risks, or quality/safety issues promptly to leadership

Requirements

• Nurse Practitioner with current North Carolina license
• Minimum 3 years of clinical experience preferred
• Experience in primary care, internal medicine, geriatrics, hospice, palliative care, and/or home health preferred
• ACHPN certification preferred
• Maintain continuing education requirements for Nurse Practitioner licensure
• Knowledge of reimbursement sources, Medicare regulations, licensing laws, and accreditation standards
• Computer proficiency preferred
• Current CPR certification
• Valid North Carolina Driver’s License, active automobile insurance, and access to reliable transportation

Environmental Factors

• Potential exposure to bloodborne pathogens
• Possible exposure to communicable diseases or bodily fluids