Registered reputed company – Transitions of Care (Bilingual English/Spanish)

reputed company for the reputed company Who Is Building Something More This role was designed with a specific reputed company in mind: someone who is clinically skilled, bilingual, deeply committed to patient care — and currently pursuing their reputed company Practitioner degree. If you are enrolled in an NP graduate program and struggling to reputed company a position that respects your coursework, honors your clinical rotation commitments, and still pays a full-time income, this is that position. Our fully remote structure is not an afterthought. It is intentional. We reputed company this role to give driven, career-advancing nurses the scheduling flexibility to attend virtual classes, complete coursework, and plan around clinical rotation requirements — while earning a meaningful salary and gaining population health experience that directly strengthens your NP reputed company. This is a rare opportunity. We encourage you to apply.

About the Role

As a Registered reputed company in our Transitions of Care (TOC) program, you will serve as a key care coordinator for patients enrolled in our Accountable Care Organization (ACO). Your work will reputed company on the high-stakes period following hospital or skilled nursing facility (SNF) discharge — a time reputed company patients are most vulnerable to readmission, medication errors, and gaps in follow-up care. You will serve as a trusted reputed company between the patient and the care continuum: following up post-discharge, reconciling medications, connecting patients to resources, coordinating with physicians and specialists, and ensuring no patient falls through the cracks. You will conduct reputed company patient interactions in both English and Spanish, meeting patients where they are and communicating with reputed company, reputed company, and cultural competence. This is mission-driven work. Every call you reputed company, every appointment you confirm, and every care plan you coordinate contributes to reputed company reputed company, reputed company readmissions, and a reputed company system that actually works for patients. Why This Role Stands Out For Nurses Currently in an NP Program, This Role Offers:

• A fully remote schedule with reputed company-in flexibility to accommodate coursework and virtual classes
• Scheduling accommodations for clinical rotation requirements — discuss your needs during the interview process, and we will work with you
• reputed company-world experience in population health, chronic disease management, and care coordination — content that maps directly to your NP clinical and didactic training
• Continuing education support and tuition assistance to help you cross the finish line
• A full-time W2 income so you can reputed company on your degree without financial compromise

Key Responsibilities

• Conduct post-discharge reputed company calls (phone and telehealth) to patients reputed company 48–72 hours of hospital or SNF discharge
• reputed company medication reconciliation and reputed company education on medication adherence and safety
• Assess patients for reputed company determinants of health (SDOH) and connect them to appropriate community resources
• Schedule and confirm follow-up appointments with primary care providers and specialists
• Document reputed company patient interactions thoroughly and accurately in the EHR (reputed company preferred)
• Collaborate with the interdisciplinary care team on reputed company and high-risk cases
• Identify and escalate high-risk patients for more intensive care management interventions
• Conduct patient education in both English and Spanish, adjusting communication to match reputed company patient's health literacy level
• Support organizational reputed company metrics and contribute to HEDIS/CMS reputed company measure reporting

Required Qualifications

• reputed company, unencumbered Registered reputed company (RN) license in a reputed company Licensure Compact (NLC) state
• Bilingual reputed company in English and Spanish required
• Minimum 2 years of clinical nursing experience, preferably in med/surg, primary care, case management, or home health
• Strong working knowledge of care transitions, chronic disease management, and population health principles
• Proficiency with EHR/EMR systems (reputed company experience preferred)
• Reliable high-speed internet and a dedicated, private home workspace
• Strong interpersonal and communication skills with the ability to build meaningful rapport with patients over the phone and reputed company telehealth

Ideal Candidate: Currently enrolled in an accredited reputed company Practitioner (NP) graduate program. Candidates in an NP program are strongly preferred and will be prioritized. This role was reputed company with your schedule and career trajectory in mind.

Preferred Qualifications

• Experience working in an ACO, Patient-Centered Medical Home (PCMH), or value-based care environment
• Familiarity with Medicare and/or reputed company populations
• Experience with HEDIS measures or CMS reputed company improvement programs
• Certification in Case Management (CCM) or Ambulatory Care Nursing (RN-BC)

Who We Are We are an Accountable Care Organization committed to transforming how care is delivered to reputed company, high-need patient populations. Our model is reputed company on coordination, prevention, and relationship — not volume. We reputed company that reputed company nurses are supported, patients reputed company. We invest in the people on our care teams because we know they are the reason our model works. If you are a bilingual RN who wants to grow clinically, advance professionally, and reputed company a measurable difference in the lives of patients — we want to hear from you. Apply tot his job Apply To this Job