Advanced Practice Provider – Transitional Care Management
About The Position
The Advanced Practice Provider in Transitional Care Management provides advanced outpatient clinical care to patients following discharge from hospitals, emergency departments, skilled nursing facilities, and other settings. The role supports continuity of care, patient recovery, and well-being through timely post-discharge assessments, medication reconciliation, individualized care planning, patient and caregiver education, and coordination with interdisciplinary teams. The position contributes to reducing avoidable readmissions and supporting value-based care outcomes. The provider practices within the scope of licensure and organizational policies, manages acute post-discharge needs and chronic conditions, identifies care gaps and social determinants of health, monitors patient progress, and documents encounters in the electronic health record. The role may require floating or traveling among clinic locations. The provider participates in interdisciplinary meetings and improvement activities and stays current on transitional care management guidelines and best practices. The position is based at Legacy Acres Homes in Houston, Texas, and is scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m. Legacy Community Health is a Federally Qualified Health Center serving the Greater Houston and Gulf Coast region.
Requirements
- Current license from the Texas Board of Nursing or as a Physician Assistant, and completion of a program at an accredited school.
- Two years of experience required.
- Obtain, maintain, and participate in Medicare and Medicaid programs, workers' compensation, other federal and state reimbursement programs, and applicable commercial insurer and health benefit programs requested by Legacy.
- Excellent communication and customer service skills.
- Ability to manage multiple deadlines and prioritize.
- Demonstrated competency with an electronic health record system.
- Ability to multitask in a fast-paced environment.
- Above-average organizational skills.
- Ability to manage confidential and sensitive information with ongoing discretion and secure information practices.
Nice To Haves
- Previous experience in an FQHC clinic setting.
- Transitional Care Management experience.
- Value-Based Care or Managed Care experience.
- Bilingual Spanish fluency.
Responsibilities
- Practice within the scope of licensure and organizational policies.
- Conduct timely post-discharge visits for recently discharged patients.
- Review essential discharge documents and patient records.
- Perform comprehensive transitional care assessments.
- Complete medication reconciliation and address discrepancies.
- Manage acute post-discharge needs and chronic conditions.
- Develop and communicate individualized post-discharge care plans.
- Identify and address gaps in care and social determinants of health.
- Provide education to patients and caregivers on key health information.
- Coordinate follow-up care with healthcare providers and agencies.
- Float or travel to multiple clinic locations to support patient care.
- Escalate urgent clinical concerns to appropriate care team members.
- Track and monitor patient progress through the post-discharge period.
- Document all care encounters accurately in the electronic health record.
- Participate in interdisciplinary care team meetings and improvement activities.
- Stay informed on transitional care management guidelines and best practices.
Benefits
- Paid time off and paid company holidays.
- Medical, dental, vision, and life insurance.
- Flexible Spending Account (FSA).
- 403(b) retirement plan with company match.
- Short-term and long-term disability.
- $0 copay for Legacy Provider visits.
- $0 copay for prescriptions filled at Legacy Pharmacies.
- Travel insurance and pet insurance.
- Subsidized gym membership.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
