Transitional Care Management Nurse Practitioner Remote

Position Overview

We are seeking a licensed Nurse Practitioner (NP) to provide Transitional Care Management (TCM) services for patients discharged from our partner skilled nursing facilities. This role focuses exclusively on conducting post-discharge patient visits via telehealth (video or phone) to support continuity of care, improve outcomes, and reduce readmissions.

Key Responsibilities

• Conduct Transitional Care Management (TCM) visits for patients following discharge from skilled nursing facilities
• Perform patient encounters via video or phone (fully remote role)
• Review and synthesize clinical data from hospital and post-acute care stays
• Assess patient status, address clinical needs, and provide appropriate care guidance
• Document visits accurately and efficiently within the designated platform
• Communicate clearly with patients, caregivers, and care teams
• Manage and maintain a full patient schedule based on availability
• Navigate clinical situations appropriately and escalate when necessary
• Utilize technology platforms to deliver care and manage workflows
• Deliver high-quality patient care exclusively in a virtual environment

Visit Structure & Work Environment

• Visits typically last up to 20 minutes per patient
• Flexible patient volume based on provider schedule and availability
• 100% remote — no field work, bedside care, or in-person clinical responsibilities
• Fully technology-enabled care delivery model

Required Qualifications

• Active and unrestricted Nurse Practitioner license
• Experience reviewing and synthesizing clinical information from hospital and post-acute care settings
• Strong clinical judgment and patient care skills
• Excellent communication and patient engagement abilities
• Highly tech-savvy and comfortable using digital health platforms
• Ability to manage schedules independently and maintain productivity
• Comfortable working exclusively in a remote, telehealth-based environment

Preferred Qualifications (Optional)

• Prior experience with Transitional Care Management (TCM) services
• Experience in skilled nursing, post-acute care, or care coordination
• Telehealth or virtual care delivery experience