Telehealth Transitional Care Nurse Practitioner

Join a remote, member-facing clinical team helping patients safely navigate the first critical days after discharge. In this full-time telehealth role, you’ll conduct Transitional Care Management visits within 14 days of discharge, complete comprehensive clinical assessments, reconcile medications, identify red flags, and coordinate care that helps reduce avoidable readmissions. This is a strong fit for a licensed Nurse Practitioner who is comfortable working independently on video, documenting same-day, and supporting members across multiple states.

This is a full-time, exempt Telehealth Transitional Care Nurse Practitioner role focused on post-discharge care. You’ll work remotely with members and caregivers through virtual visits, helping close care gaps, support safe recovery, and escalate urgent clinical concerns when needed.

• Employment type: Full-time, exempt
• Work model: Remote / telehealth
• Schedule: Core hours of 8:00 AM – 5:00 PM Central Time, Monday through Friday
• Weekend coverage: Rotating weekend coverage required for urgent or emergent needs, which may include a Saturday visit when clinically necessary
• Start: ASAP
• Compensation: $135,000 salary

• Conduct telehealth TCM visits within the required post-discharge window.
• Perform comprehensive clinical assessments for recently discharged members.
• Complete medication reconciliation and identify potential safety, adherence, or care-continuity concerns.
• Support members and caregivers through video visit connection steps, basic troubleshooting, and maintaining a private, HIPAA-compliant encounter environment.

• Identify acute clinical needs and escalate urgent findings according to clinical protocols.
• Serve as a first-line clinical escalation resource for care coordinators and support staff regarding member status, red-flag symptoms, or scheduling issues with clinical implications.
• Coordinate with care team members who interface with PCPs, specialists, and discharge planning teams to help close care gaps and reduce readmission risk.
• Adjust daily visit sequencing as needed based on member cancellations, discharge timing, and care priorities.

• Document all encounters completely and accurately.
• Submit charts no later than the date of service to support timely coding, quality reporting, and claims submission.
• Maintain compliance with HIPAA, state licensure, and payer-specific documentation requirements.
• Participate in ongoing clinical training, chart audit feedback sessions, and quality improvement initiatives.

• Active, unrestricted Nurse Practitioner licensure in at least three of the following states: OH, CA, NY, IN, KY, PA, LA, MI, TN, MO.
• Active national board certification through AANP or ANCC as an FNP, AGNP, or equivalent adult/geriatric-focused certification.
• Minimum of 2 years of clinical experience.
• Comfort delivering care through video visits and communicating clearly with members and caregivers in a remote setting.
• Ability to work a dependable weekday schedule with rotating weekend coverage for urgent or emergent clinical needs.
• Strong comfort using EMR documentation platforms, video-visit software, and desktop or mobile point-of-care technology.
• Ability to complete accurate same-day documentation for all encounters.

• Prior telemedicine or telehealth experience.
• Transitional Care Management or post-discharge care experience.
• Experience working with Medicare Advantage populations.
• Familiarity with HEDIS, STAR measures, and value-based care documentation standards.
• Experience in a fast-paced, discharge-driven scheduling environment.

• Dedicated, private, HIPAA-compliant workspace free from background noise and visual distractions during scheduled video visits.
• Reliable high-speed internet connection sufficient for stable, uninterrupted video visits.
• Personal computer and webcam setup that can support secure video visits and required clinical documentation tools.
• Ability to remain seated, attentive, and engaged on camera for consecutive video visits throughout the scheduled shift.

We are an Equal Opportunity Employer. This job description reflects the general nature of the role and is not an exhaustive list of duties.