Transitional Care Clinic Nurse Practitioner

Job Requirements

The Advanced Practice Provider (APP) - Transitional Care and Community Outreach provides comprehensive outpatient care for patients in the Transitional Care Center. The APP delivers patient-centered primary and transitional care services aimed at improving access to care, supporting safe transitions from hospital to home, and addressing healthcare disparities within vulnerable populations.

In the Transitional Care Clinic, the APP evaluates and manages patients recently discharged from the hospital who require short-term medical management prior to establishing care with a primary care provider or while awaiting follow-up with their existing provider. The role focuses on reducing hospital readmissions, optimizing medication management, and ensuring safe and coordinated care transitions.

The APP collaborates with physicians, specialists, case managers, social workers, and other healthcare professionals to coordinate care and support improved patient outcomes.

The APP practices within the scope of professional licensure, national certification, institutional credentialing, and delineation of privileges in accordance with applicable state regulations and hospital policies.

Responsibilities may include:

1. Performing comprehensive post-hospitalization evaluations including review of discharge summaries, hospital course, and treatment plans.
2. Conducting patient assessments including medical history review, physical examination, and diagnostic evaluation.
3. Managing acute and chronic medical conditions following hospitalization.
4. Performing medication reconciliation and adjusting medication regimens based on clinical status and discharge instructions.
5. Ordering and interpreting laboratory tests, diagnostic imaging, and other studies necessary to support ongoing care.
6. Identifying and managing complications that may arise following hospitalization.
7. Providing patient and family education regarding diagnoses, medications, treatment plans, and warning signs requiring medical attention.
8. Facilitating safe care transitions through coordination with primary care providers, specialists, and community resources.
9. Assisting patients in establishing care with a primary care provider when one is not currently established.
10. Supporting initiatives aimed at reducing hospital readmissions and improving transitional care outcomes.
11. Collaborates with physicians, specialists, case managers, social workers, and community resources to coordinate patient care.
12. Facilitates referrals to specialty care, behavioral health services, rehabilitation programs, or community support services.
13. Assists patients in accessing financial assistance programs, medication affordability resources, and community health programs when appropriate.

Work Experience

1. Graduate of an accredited Nurse Practitioner or Physician Assistant program.
2. Current and unrestricted state licensure as a Nurse Practitioner or Physician Assistant.
3. Current national certification through an approved certifying body (ANCC, AANP, or NCCPA).
4. Current Basic Life Support (BLS) certification required.
5. Prior experience in primary care, hospital medicine, internal medicine, family medicine, or transitional care preferred.
6. Bilingual candidates preferred

Benefits

• Please review 2026-2027 UMMS Benefits Guide.pdf