About the role
Position Summary
The Nurse Practitioner provides virtual clinical care for patients recently discharged from the hospital and for patients identified as high risk or needing follow up. The NP conducts telehealth assessments, manages care plans, completes medication reconciliation, and supports field clinicians who complete in home visits. This fully remote role supports readmission avoidance, care continuity, and patient stabilization across Georgia and Arizona.
Key Responsibilities
- Conduct virtual clinical assessments for post discharge visits and follow up visits
- Complete medication reconciliation and update patient care plans
- Provide real time support for EMTs during in home assessments
- Document findings in accordance with regulatory standards
- Address clinical quality gaps within NP scope
- Ensure follow up appointments, referrals, and testing are addressed
- Communicate with hospitals, primary care providers, and care partners when needed
- Provide clinical oversight for tasks delegated to EMTs, CHWs, and Social Workers
- Participate in interdisciplinary discussions and reviews
- Adhere to CMS, state, and accreditation requirements
Minimum Requirements:
• Active Arizona NP license or ability to obtain within thirty days
• Registered with AHCCCS preferred
• Experience with chronic conditions and care management preferred
• Experience in telehealth or transitions of care is helpful
• Ability to support field teams remotely
• Primary care, internal medicine focused >5 years of clinical experience
• Outpatient (home visits, clinic setting) experience required - exclude candidates with inpatient experience only (ER/Surgical) or academic or research
• Experience with annual comprehensive visits, management of patients with multiple chronic conditions is a plus. (not required)
• Familiarity with HCC coding, HEDIS measures is a plus (not required)
• Telehealth experience preferred (not required)
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