Transitional Care Nurse Practitioner

2 weeks ago

Chicago IL United States Oak Street Health Full time
Company: Oak Street Health

Title: Transitional Care Nurse Practitioner

Location: IL

Role Description

The Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in delivering in-home support and care following adverse events, which include inpatient admissions. APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up. Provider teams enjoy easy access to clinical support from peers and medical directors and use best in class population health data to support patients when they need it most.

Core Responsibilities

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 Streetâs electronic medical record

Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting

Other duties, as assigned

What are we looking for

Genuine passion for reaching vulnerable patients

Strong clinical skills focused on older adults with complex disease states

Comfort navigating visits in patient homes

Demonstrated ability to collaborate effectively in a team setting

Willingness to learn and be accountable for visit documentation and workflows

Excellent communication, follow-up, teamwork, and problem-solving skills

Desire to be a part of a fast-paced, innovative, quality-driven organization

Required Qualifications

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.

Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required

What does being Oaky look like?

Radiating positive energy

Assuming good intentions

Creating an unmatched patient experience

Driving clinical excellence

Taking ownership and delivering results

Being relentlessly determined

Why Oak Street Health?

Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.

Oak Street Health Benefits:

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients

Paid vacation, sick time, and investment/retirement 401K match options

Health insurance, vision, and dental benefits

Opportunities for leadership development and continuing education stipends

New centers and flexible work environments

Opportunities for high levels of responsibility and rapid advancement

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health

  • Registered Nurse

    1 month ago

    Bend, OR, United States Bend Transitional Care Full time

    Registered Nurse/RNSetting: Skilled NursingStatus: Full-TimeShift: NightsWage: "New Competitive Wage Scale"Location: Bend Transitional Care- 900 NE 27th St. Bend, OR 97701Join Avamere today and experience a strong and exciting team environment with a group decision-making culture! Whether you're a recent graduate, a skill-seeking individual, or an ambitious...

  • Certified Nursing Assistant

    4 weeks ago

    Bend, OR, United States Bend Transitional Care Full time

    Certified Nursing Assistant (CNA)Setting: Skilled NursingWage: $21.25 And Up, Depending on ExperienceType: Full-Time and Part-TimeShift: Part-Time Weekends (all shifts), Part-Time Thursday and Friday 2p-10pFull-Time 10p-6a shiftFull-Time 2p-10p - Thursday through SundayShift Differential: $1.00 for Evening Shift and $2.00 for NOC ShiftLocation: Bend...

  • Certified Nursing Assistant

    1 week ago

    Salem, OR, United States Salem Transitional Care Full time

    Certified Nursing Assistant/CNAType: Full-TimeShift: Day: 6am - 2pm, Eve: 2pm - 10pm, NOC: 10pm - 6amShift Differential: $1.00 for Evening Shift and $1.50 for NOC ShiftLocation: Salem Transitional Care - 3445 Boone Rd SE, Salem, OR 97317 Employee Perks:Tuition assistanceMentorship opportunitiesCareer developmentEmployee assistance program featuring...

  • Certified Medication Aide

    2 weeks ago

    Salem, OR, United States Salem Transitional Care Full time

    Certified Medication Aide (CMA)Status: Full-TimeShift: DAY & EVE ShiftSchedule: Variable scheduleLocation: Salem Transitional Care - 3445 Boone Rd SE, Salem, OR 97317Employee Perks:Tuition assistanceMentorship opportunitiesCareer developmentEmployee assistance program featuring counseling services, financial coaching, free legal services and moreGenerous...

  • Nurse Practitioner

    1 week ago

    Chicago, IL, United States MedAdventures Full time

    *MedAdventures*, a division of Icon Medical Network, is looking for a *Geriatric Nurse Practitioner *to join our partner's full-time team in *Chicago, IL*. This opportunity offers great pay, benefits, and some flexibility with your schedule!*This is a DIRECT HIRE opportunity (*_*not*_ *locums or contract). **ESSENTIAL RESPONSIBILITIES** Demonstrates both...

  • Transitional Care Nurse Practitioner

    1 week ago

    Chicago, United States Oak Street Health Full time

    Company: Oak Street HealthTitle: Transitional Care Nurse PractitionerLocation: ILRole DescriptionThe Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in...

  • Physician Assistant or Nurse Practitioner

    2 months ago

    Chicago, United States Northwestern Memorial Healthcare Full time

    Company Description At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the...

  • Advanced Practice Provider

    4 days ago

    Chicago, Illinois, United States Northwestern Memorial Healthcare Full time

    Job SummaryWe are seeking a highly skilled Physician Assistant or Nurse Practitioner to join our team at Northwestern Memorial Healthcare's Transitional Care Clinic. As a key member of our interdisciplinary team, you will play a vital role in providing high-quality, patient-centered care to at-risk patients with complex medical and psychosocial needs.Key...

  • Nurse Practitioner

    1 week ago

    Chicago, IL, United States HealthDrive Full time

    Overview:HealthDrive is looking for a Nurse Practitioner to manage the medical needs of skilled nursing residents in both the sub-acute rehab and long-term care units. The Nurse Practitioner will diagnose and treat health conditions, promote good health practices, and work collaboratively as a member of the medical staff. The APRN will also establish and...

  • Primary Care Nurse Practitioner

    1 week ago

    , CA, United States Opportunity Healthcare Full time

    Join Our Team as a Primary Care Nurse PractitionerAbout Opportunity Healthcare:Opportunity Healthcare is a premier locum tenens and staffing agency dedicated to 'Connecting the Best in Healthcare.' We are currently seeking a committed Advanced Practitioner to join a caring healthcare facility that serves a diverse community.Your Role:Position: Family Nurse...

  • Nurse Practitioner

    4 days ago

    Chicago, Illinois, United States Ascension Full time

    Job SummaryWe are seeking a skilled Nurse Practitioner to join our team at Ascension. As a key member of our healthcare team, you will provide high-quality patient care and work collaboratively with our medical staff to deliver exceptional patient outcomes.ResponsibilitiesProvide direct patient care, including assessing patient needs, developing and...

  • Nurse Practitioner Position in Geriatric Care

    2 weeks ago

    , OH, United States Opportunity Healthcare Full time

    Position Overview Opportunity Healthcare is seeking a dedicated Nurse Practitioner to provide exceptional care in a full-time, permanent role focused on inpatient services. This position is tailored for those passionate about Geriatric and Palliative medicine. Key Details Exclusively for Nurse Practitioners Full-time commitment with a structured schedule...

  • Advanced Practice Provider

    2 weeks ago

    Chicago, Illinois, United States Northwestern Memorial Healthcare Full time

    Company Overview At Northwestern Memorial Healthcare, we believe that every interaction with our patients is crucial in fostering a supportive work environment. Our commitment to a patient-centered approach distinguishes us as a frontrunner in the healthcare sector. As a vital member of our organization, you will have the chance to contribute to our mission...

  • Nurse Practitioner

    4 weeks ago

    New Tazewell, TN, United States Exceptional Care Services Full time

    Exceptional Care Services is seeking a Primary Care Nurse Practitioner for our New Tazewell, TN market.SUMMARYExceptional Care Services is seeking a skilled Nurse Practitioner with long-term care experience to join our team. Our practice provides high quality medical services to our residents in our care centers. This position is a full-time salaried offer...

  • Primary Care Nurse Practitioner

    1 month ago

    Bloomington, IL, United States National Staffing Solutions Full time

    At National Staffing Solutions, we have the privilege and honor of working with dedicated healthcare professionals that make a positive impact in aiding those needing healthcare services across the U.S. every day. It is our passion, drive and integrity that enables us to continue our focus in assisting remarkable healthcare professionals like yourself in...

  • Engagement APP- Nurse Practitioner

    2 months ago

    Chicago, IL, United States Wellbe Senior Medical Full time

    Job Summary: WELLBE INTRODUCTION The WellBe care model is a Physician Led Advanced Practice clinician driven geriatric care (care of older adults) team focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients.  This population is typically underserved and very challenged with access to care.   To address these problems, we...

  • Clinical Transition Educator

    2 days ago

    Chicago, Illinois, United States Option Care Health Full time

    Job DescriptionJob Summary:The Clinical Transition Educator is a key member of the Option Care Health team, responsible for providing clinical education and training to ensure successful transition of patients to our care delivery model.Key Responsibilities:Evaluate, educate, and train patients, caregivers, and facility staff about our services and products...

  • Nurse Practitioner

    4 weeks ago

    Dayton, OH, United States Exceptional Care Services Full time

    Exceptional Care Services is hiring a Primary Care Nurse Practitioner for the Dayton, OH market!We're adding to our team and want you!Primary Care Nurse PractitionerExceptional Care Services is seeking a skilled Nurse Practitioner with long-term care experience to join our team. Our practice provides high quality medical services to our residents in our care...

  • Nurse Practitioner

    4 weeks ago

    Greensburg, IN, United States Exceptional Care Services Full time

    Exceptional Care Services is hiring a Primary Care Nurse Practitioner for the Greensburg, IN market!We're adding to our team and want you!Primary Care Nurse PractitionerExceptional Care Services is seeking a skilled Nurse Practitioner with long-term care experience to join our team. Our practice provides high quality medical services to our residents in our...

  • Nurse Practitioner

    4 weeks ago

    Dover, TN, United States Exceptional Care Services Full time

    Exceptional Care Services is seeking a PT Primary Care Nurse Practitioner for our Dover, TN market.SUMMARYExceptional Care Services is seeking a skilled Nurse Practitioner with long-term care experience to join our team. Our practice provides high quality medical services to our residents in our care centers. This position is a full-time salaried offer with...