Advanced Practice Provider Transitional Care Management

Advanced Practice Provider in Transitional Care ManagementImagine being part of a team where every day you make an impact on someone's journey to recovery. As an Advanced Practice Provider in Transitional Care Management at Legacy Community Health, you will play a pivotal role in providing advanced clinical care to patients after they've been discharged from hospitals, emergency departments, skilled nursing facilities, and more. This is your opportunity to be at the heart of patient care, ensuring continuity and promoting well-being in the outpatient setting.Schedule: Monday-Friday (8AM-5PM)Locations: Legacy Acres Homes (3011 W Gulf Bank Road, Houston Texas 77099)Focus on meaningful post-discharge assessments and medication reconciliation.Develop personalized care plans and educate patients and caregivers.Collaborate with interdisciplinary teams to enhance patient recovery.Be an integral part of reducing avoidable readmissions and supporting value-based care outcomes.Key ResponsibilitiesPractice within the scope of licensure and organizational policies.Conduct timely post-discharge visits for recently discharged patients.Review essential discharge documents and patient records.Perform comprehensive transitional care assessments.Complete medication reconciliation and address discrepancies.Manage acute post-discharge needs and chronic conditions.Develop and communicate individualized post-discharge care plans.Identify and address gaps in care and social determinants of health.Provide education to patients and caregivers on key health information.Coordinate follow-up care with various healthcare providers and agencies.Float or travel to multiple clinic locations to support patient care.Escalate urgent clinical concerns to appropriate care team members.Track and monitor patient progress through the post-discharge period.Document all care encounters accurately in the electronic health record.Participate in interdisciplinary care team meetings and improvement activities.Stay informed on transitional care management guidelines and best practices.Minimum QualificationsCurrent license from the Texas Board of Nursing or Physician Assistant and completion of program at an accredited school.Provider shall obtain, maintain and participate in the Medicare and Medicaid Programs, workers compensation, other federal and state reimbursement programs, and the payment plan of any commercial insurer, health maintenance organization, preferred provider organization, accountable health plan, and other health benefit program requested by Legacy.2 years of experience is required.Previous experience in an FQHC clinic setting is preferred.Transitional Care Management experience is preferred.Value Based Care/Managed Care experience highly desirable.Excellent communication skills and customer service skills.Must be able to manage multiple deadlines and prioritize.Demonstrated competency with an EHRS system.Ability to multitask in a fast-paced environment.Above average organizational skills.This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.Bilingual / Spanish fluency desirable.About Legacy Community HealthAs the largest Federally Qualified Health Center (FQHC) in Southeast Texas, Legacy Community Health has been delivering comprehensive, high-quality, and affordable health care for nearly 40 years. With more than 50 clinics across the Greater Houston and Gulf Coast region, we continue to grow strategically and invest in our communities. By innovating how care is delivered, we've stayed at the forefront of connecting our communities to healthevery day, in every way. At Legacy, we know our success is powered by our people. We're always looking for talented, passionate individuals who want more than a jobthey want a meaningful career that makes a real impact. Explore our open positions and see if a career at Legacy is right for you.At Legacy Community Health, our missionDriving healthy change in our communitiesguides everything we do. To fulfill this mission, every team member is expected to embody the following core attributes in their daily work, regardless of role or department:Approachable & CollaborativeWe bring our expertise without ego. In a collaborative healthcare environment, humility fosters trust and teamwork. Our employees value diverse perspectives, seek input from others, and are unafraid to acknowledge when they need help. We stay grounded in our purpose: to serve patients and communities with compassion and humility.Driven & CommittedWe are driven by a deep commitment to excellence in patient care and organizational improvement. Our employees take initiative, embrace challenges, and go the extra mile to support our mission. Whether improving patient outcomes, streamlining processes, or stepping up in times of need, we are always striving to drive healthy changewithin ourselves, our teams, and the communities we serve.Perceptive & Thoughtful CommunicatorsWe value emotional intelligence as much as clinical or technical skill. Our team members demonstrate sound judgment, cultural sensitivity, and the ability to navigate complex situations with empathy and professionalism. They communicate clearly and respectfully with patients, families, and colleagues, building trust and fostering a safe, inclusive environment for all.