JOB ACCOUNTABILITIES

• Performs comprehensive transition-focused clinical assessments and develops, implements, and directs individualized transition support plans for patients participating in the Multidisciplinary Transitional Support Program (MTSP).
• Provides advanced clinical management across the continuum of care to support safe, coordinated transitions from hospitalization to the patient's longitudinal care team in collaboration with the supervising physician.
• Monitors patient progress, performs ongoing clinical reassessment, modifies the plan of care as clinically indicated, and facilitates timely escalation of care.
• Performs medication reconciliation, optimizes medication management, and provides patient and caregiver education to support safe transitions of care.
• Collaborates with physicians and the interdisciplinary team to coordinate care across the healthcare continuum.
• Identifies clinical, psychosocial, and social barriers to recovery and facilitates appropriate interventions and community resources.
• Documents assessments, interventions, care plans, and patient outcomes accurately in the electronic health record.
• Supports the development, implementation, and evaluation of clinical workflows, program processes, and best practices to advance the MTSP.
• Participates in quality improvement, workflow optimization, program evaluation, and implementation of evidence-based transitional care practices.
• Practices in accordance with approved standardized procedures, organizational policies, applicable regulatory requirements, and the California Nurse Practice Act.

SKILLS AND KNOWLEDGE

• Knowledge of advanced nursing practice, clinical assessment, diagnostic reasoning, pharmacology, pathophysiology, and evidence-based management of medically complex adult patients.
• Knowledge of transitional care, care coordination, medication management, chronic disease management, and continuity across healthcare settings.
• Understanding of social determinants of health and available community resources.
• Strong communication, collaboration, critical thinking, clinical decision-making, and organizational skills.
• Proficiency with Electronic Health Record and Microsoft Office applications.
• Ability to work independently while collaborating effectively with physicians and interdisciplinary teams.
• Commitment to patient-centered care, professional accountability, continuous learning, and quality improvement.

MINIMUM QUALIFICATIONS

• Master's or Doctoral degree from an accredited Nurse Practitioner program.
• Minimum of five (5) years of inpatient Nurse Practitioner experience.
• Strong clinical assessment, diagnostic reasoning, communication, and critical thinking skills.

PREFERRED QUALIFICATIONS

• Acute Care Nurse Practitioner (AGACNP or ACNP) certification preferred.
• Experience with discharge planning or transitions of care preferred.
• Experience with Epic electronic health record preferred.

LICENSURE / CERTIFICATION

• Current California Registered Nurse license and Advanced Practice Nurse licensure.
• National Nurse Practitioner certification.
• Basic Life Support (BLS).
• Advanced Cardiovascular Life Support (ACLS).
• DEA registration.

SCHEDULE

• M-F, 5 8hr shifts/week