Nurse Practitioner, Care Transitions (Dual Board-Certified)

Avail Health•Rockville, MD

2d•$137,500 - $172,500•Hybrid

About The Position

You’ll serve as the billing provider for Avail Health’s 30-day TCM episode — conducting comprehensive post-discharge visits, primarily virtual, within 1–14 days of hospital discharge. Your patients are Medicare-age adults navigating complex medical and behavioral health needs after a hospitalization. Your job is to assess, stabilize, and connect them to the right next level of care before the window closes. You’ll work inside a tight interdisciplinary team (RN Care Manager, SW Care Manager, Care Coordinator) supported by HIE integrations and an ambient AI scribe. The workflow overhead is handled. You focus on the clinical judgment. This is a founding role in a newly launching program. You’ll help build the model, not just run it.

Requirements

Active Maryland NP license; MSN or DNP from an accredited program
Dual board certification: AGPCNP-BC + PMHNP-BC, or FNP-C/FNP-BC + PMHNP-BC
3+ years of independent NP experience in both psychiatric/mental health and adult primary or acute care
Maryland DEA registration (or eligibility to obtain prior to start)
Experience in post-hospital transitions, mobile care (home health, hospice, house calls), or complex care coordination
Valid driver’s license and reliable transportation

Nice To Haves

Geriatric experience strongly preferred
Familiarity with TCM billing, CMS documentation standards, or interdisciplinary Medicare programs
Experience with frailty, polypharmacy, dementia, or complex behavioral health presentations in older adults
Familiarity with telehealth platforms, HIE systems, or ambient AI documentation tools

Responsibilities

Serve as the billing provider for Avail Health’s 30-day TCM episode, conducting comprehensive post-discharge visits, primarily virtual, within 1–14 days of hospital discharge.
Assess, stabilize, and connect patients to the right next level of care.
Manage the TCM billing encounter and CMS compliance for each patient’s 30-day episode.
Make medication reconciliation decisions and exercise prescription authority within scope.
Perform clinical risk stratification at the point of the TCM visit and escalate when patients need a higher level of care.
Conduct virtual TCM visits within 1–14 days of discharge; conduct mobile in-person visits when patients can’t be seen remotely.
Perform medication reconciliation and document moderate- to high-complexity MDM at the time of each TCM encounter.
Apply dual-specialty (medical + behavioral health) judgment to assess complexity and initiate the right post-discharge intervention.
Facilitate warm handoffs into behavioral health, dementia care management, and chronic disease programs for qualifying patients.
Participate in daily team huddles to review the panel, flag high-risk cases, and align on care priorities.
Complete visit documentation same-day using an ambient AI scribe; ensure full CMS billing compliance.