Provide video-based follow-up and chronic care visits for members, with a strong focus on medication review, care transitions after hospital or emergency department discharge, and plain-language counseling for older adults. This role also supports care coordination by identifying social and clinical needs, escalating concerns, and communicating plans to primary care providers. The clinician serves as a day-to-day clinical resource for nurses, social workers, and care navigators in an early-stage telehealth care navigation program.
Key Responsibilities
- Conduct telehealth visits for chronic condition check-ins, medication reconciliation, and follow-up care.
- Assess member health status, clinical needs, and social needs, and document clear care plans and next steps.
- Provide post-discharge follow-up after hospital or emergency department visits, including warning-sign education and medication review.
- Coordinate with the care team to identify members at risk of readmission and support follow-up care.
- Serve as a clinical resource for RNs, LCSWs, and care navigators, and respond to same-day clinical escalations.
- Support training on clinical red flags, medication basics, and escalation criteria.
- Communicate findings and recommendations to primary care providers to support continuity of care.
- Complete accurate, same-day documentation and follow telehealth, privacy, and consent requirements.
Required
- Board certification as a Family Nurse Practitioner (FNP) or Adult-Gerontology Nurse Practitioner (AGNP).
- Active, unrestricted APRN license in at least one U.S. state.
- 3+ years of nurse practitioner experience in primary care, internal medicine, geriatrics, or transitional care.
- Availability during core business hours Monday through Friday, Eastern Time.
- Authorization to work in the United States without employer sponsorship.
- Ability to use telehealth platforms, EHRs, and care management tools.
Preferred
- Licensure in multiple states.
- Active DEA registration.
- Experience with Medicare, dual-eligible, or older adult populations.
- Telehealth, home-based care, or transitional care experience.
- Bilingual Spanish language skills.
Benefits & Perks
- 100% remote work.
- Competitive compensation.
- Health insurance.
- PTO and holidays.
- Opportunity to help shape an early-stage clinical program.
- Close partnership with care navigation leadership and program operations.