Remote Nurse Practitioner — Transitional Care & Readmission Prevention

Luminis Health; United States; Remote; USD 110,000 - 140,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

PTO & Holidays

Retirement Plan

Tuition Assistance

Wellness Programs

Employee Referral Bonus

Life Insurance

Disability Insurance

Job summary

Luminis Health seeks an experienced Nurse Practitioner to join its Transitional Care Service in a fully remote position. You will perform virtual post-discharge care for complex patients, conduct 24-72 hour assessments, and coordinate with PCPs and SNFs to prevent readmissions.

Responsibilities include medication reconciliation, care planning, and patient education, with emphasis on telehealth visits and Epic documentation. Strong collaboration and independent decision-making are essential.

Qualifications

• Current Maryland NP or PA license in good standing.
• National certification through AANP/ANCC (NP) or NCCPA (PA-C).
• Minimum 2 years of experience in acute care, hospital medicine, transitional care, case management, or care coordination.
• Experience managing medically complex or high-risk patients.
• Proficiency with Epic and telehealth platforms preferred.

Responsibilities

• Conduct post-discharge telephone and video assessments within 24-72 hours of hospital discharge.
• Provide telehealth follow-up visits for high-risk patients.
• Perform medication reconciliation and resolve medication discrepancies.
• Assess and manage acute clinical needs within APP scope of practice.
• Coordinate care with PCPs, specialists, pharmacies, SNFs, home health agencies, and community resources.
• Serve as a clinical point of contact for patients and caregivers throughout the transitional period.
• Provide education regarding medications, disease management, warning signs, and follow-up care.
• Coordinate appointments and services during the patient's 30-day transitional care period.
• Document patient encounters, care plans, communications, and outcomes in Epic.

Skills

Clinical judgment

Independent decision-making

Communication

Time management

Telehealth proficiency

HIPAA compliance

Tools

Epic

Telehealth platforms

Job description

Luminis Health seeks an experienced Nurse Practitioner to join its Transitional Care Service in a fully remote position. You will perform virtual post-discharge care for complex patients, conduct 24-72 hour assessments, and coordinate with PCPs and SNFs to prevent readmissions.

Responsibilities include medication reconciliation, care planning, and patient education, with emphasis on telehealth visits and Epic documentation. Strong collaboration and independent decision-making are essential.