Nurse Practitioner, Care Transitions

Avail Health•Rockville, MD

1d•$137,500 - $172,500•Hybrid

About The Position

Avail Health is launching a hospital-based Care Transitions Program supporting Medicare patients with complex medical, behavioral health, and social needs following discharge. The Nurse Practitioner, Care Transitions is the clinical anchor of the post-discharge episode - the billing provider for Avail Health's 30-day Transitional Care Management (TCM) program. You'll deliver comprehensive post-discharge visits, primarily via virtual care, within 1–14 days of hospital discharge. Your work includes clinical assessment, medication reconciliation, risk stratification, and moderate- to high-complexity medical decision-making to support safe transitions and reduce avoidable readmissions. You'll work within a purpose-built interdisciplinary team alongside an RN Care Manager, SW Care Manager, and Care Coordinators, supported by HIE integrations and an ambient AI scribe. When patients can't be seen virtually, you'll conduct mobile in-person visits across the Montgomery County region. This is a founding clinical role. The program infrastructure is being built around it.

Requirements

MSN or DNP from an accredited program
Active, unrestricted Maryland NP license in good standing
Dual board certification: AGPCNP-BC + PMHNP-BC, or FNP-C/FNP-BC + PMHNP-BC
Minimum 3 years of independent NP clinical experience in both psychiatric/mental health and adult primary or acute care; geriatric experience strongly preferred
Active Maryland DEA registration, or eligibility and willingness to obtain prior to start
Experience with post-hospital transitions of care, discharge planning, or complex care coordination
Experience in mobile care settings (home health, hospice, house calls, or similar)
Comfort operating in a virtual-first, technology-enabled environment with evolving workflows
Valid driver's license, reliable transportation, and active automobile insurance

Nice To Haves

Experience in TCM, hospital readmission reduction, longitudinal care management, complex case management, population health, or interdisciplinary Medicare programs
Familiarity with CMS TCM billing and documentation requirements
Experience with Medicare-aged populations with complex comorbidities, frailty, polypharmacy, behavioral health conditions, or dementia-related needs
Familiarity with telehealth platforms, HIE systems, ambient AI documentation tools, or e-consult platforms

Responsibilities

Clinical delivery of the 30-day TCM episode - from post-discharge visit through transition to longitudinal care
Billing compliance and documentation accuracy for all TCM encounters
Clinical decision-making for a complex, high-risk Medicare patient panel with medical, behavioral health, and psychosocial needs
Serve as the billing provider for Avail Health's TCM episode, conducting comprehensive post-discharge visits within 1–14 days of hospital or post-acute discharge
Perform clinical assessment, medication reconciliation, risk stratification, and moderate- to high-complexity medical decision-making
Identify gaps in care, initiate diagnostic or treatment interventions, and coordinate with specialists and community resources to support safe transitions
Participate in daily team huddles with the RN Manager, RN Care Manager, SW Care Manager, and Care Coordinators for panel review, risk escalation, and coordinated care planning
Use an ambient AI scribe to support real-time documentation; complete all TCM billing elements accurately and in compliance with CMS requirements
Support continuity of care for high-risk patients throughout and beyond the TCM episode, including warm handoffs into longitudinal care management programs
Contribute frontline clinical feedback to support workflow refinement, protocol development, and program improvement as the program scales