Transitional Care Clinic Nurse Practitioner

University of Maryland Medical System; Towson (MD); On-site; USD 110,000 - 150,000; Full time

Benefits offered by this job

Benefits package

Job summary

The University of Maryland Medical System seeks an Advanced Practice Provider (APP) for Transitional Care and Community Outreach to deliver primary and transitional care to recently discharged patients in Towson, MD. The role focuses on reducing readmissions, optimizing medications, and coordinating safe transitions to home.

You will evaluate post-discharge patients, manage chronic conditions, reconcile medications, and educate patients and families while collaborating with physicians, case

Qualifications

• Graduate of an accredited NP or PA program.
• Current and unrestricted state licensure as NP or PA.
• Current national certification (ANCC, AANP, or NCCPA).
• Current Basic Life Support (BLS) certification.
• Experience in primary care, hospital medicine, internal medicine, family medicine, or transitional care preferred.
• Bilingual candidates preferred.

Responsibilities

• Perform post-hospitalization evaluations including discharge review and treatment plans.
• Assess medical history, perform exams, and order/interpret tests as needed.
• Manage post-discharge conditions and adjust regimens accordingly.
• Coordinate safe care transitions with PCPs, specialists, and community resources.
• Educate patients and families about diagnoses, meds, and warning signs.
• Assist patients in establishing care with PCPs when not already in place.

Skills

Bilingual

Care coordination

Patient education

Medication reconciliation

Education

Graduate of an accredited Nurse Practitioner program

Graduate of an accredited Physician Assistant program

Job description

Job Requirements

The Advanced Practice Provider (APP) – Transitional Care and Community Outreach provides comprehensive outpatient care for patients in the Transitional Care Center. The APP delivers patient-centered primary and transitional care services aimed at improving access to care, supporting safe transitions from hospital to home, and addressing healthcare disparities within vulnerable populations.

Job Requirements

The Advanced Practice Provider (APP) – Transitional Care and Community Outreach provides comprehensive outpatient care for patients in the Transitional Care Center. The APP delivers patient-centered primary and transitional care services aimed at improving access to care, supporting safe transitions from hospital to home, and addressing healthcare disparities within vulnerable populations.

In the Transitional Care Clinic, the APP evaluates and manages patients recently discharged from the hospital who require short-term medical management prior to establishing care with a primary care provider or while awaiting follow-up with their existing provider. The role focuses on reducing hospital readmissions, optimizing medication management, and ensuring safe and coordinated care transitions.

The APP collaborates with physicians, specialists, case managers, social workers, and other healthcare professionals to coordinate care and support improved patient outcomes.

The APP practices within the scope of professional licensure, national certification, institutional credentialing, and delineation of privileges in accordance with applicable state regulations and hospital policies.

Responsibilities May Include

• Performing comprehensive post-hospitalization evaluations including review of discharge summaries, hospital course, and treatment plans.
• Conducting patient assessments including medical history review, physical examination, and diagnostic evaluation.
• Managing acute and chronic medical conditions following hospitalization.
• Performing medication reconciliation and adjusting medication regimens based on clinical status and discharge instructions.
• Ordering and interpreting laboratory tests, diagnostic imaging, and other studies necessary to support ongoing care.
• Identifying and managing complications that may arise following hospitalization.
• Providing patient and family education regarding diagnoses, medications, treatment plans, and warning signs requiring medical attention.
• Facilitating safe care transitions through coordination with primary care providers, specialists, and community resources.
• Assisting patients in establishing care with a primary care provider when one is not currently established.
• Supporting initiatives aimed at reducing hospital readmissions and improving transitional care outcomes.
• Collaborates with physicians, specialists, case managers, social workers, and community resources to coordinate patient care.
• Facilitates referrals to specialty care, behavioral health services, rehabilitation programs, or community support services.
• Assists patients in accessing financial assistance programs, medication affordability resources, and community health programs when appropriate.

Work Experience

• Graduate of an accredited Nurse Practitioner or Physician Assistant program.
• Current and unrestricted state licensure as a Nurse Practitioner or Physician Assistant.
• Current national certification through an approved certifying body (ANCC, AANP, or NCCPA).
• Current Basic Life Support (BLS) certification required.
• Prior experience in primary care, hospital medicine, internal medicine, family medicine, or transitional care preferred.
• Bilingual candidates preferred

Benefits

• Please review 2026-2027 UMMS Benefits Guide.pdf

All information will be kept confidential according to EEO guidelines. We do not accept inquiries or solicitations from 3rd party recruiters/search firms.