Nurse Practitioner - Transitional Care Program

Nurse Practitioner – Transitional Care Program

Have an active, non-probationary state medical license, including US work authorization, if applicable
1+ years APN experience, preferably with a Medicare population
Experience in home-based care (as RN or APP) preferred
Flexibility to travel throughout service area
Electronic Medical Record experience
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.

Provide post-discharge support according to defined pathways within the patient’s home
Develop care plans and individualize goals of care with patient, their families, and their providers
Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges
Collaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialists
Structure and prioritize scheduling based on clinical complexity for both new and routine patients
Recognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissions
Provide after-hours and weekend call support, shared with other in state providers
Facilitate and conduct goals of care and advance care planning discussions with patients and families
Assess and evaluate family / caregiver needs and limitations
Teach patients, caregivers, and others about their health conditions
Accurate and timely documentation of patient encounters in Oak Street’s electronic medical record
Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
Other duties, as assigned

Experience in home-based care (as RN or APP) preferred
Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required