NP Care Transitions - Adventist Simi Valley - 101017

Job Description

Performs organization competencies for outpatient care transition for narrow network and Medicare patients. Maintains responsibility for supervising Medical Assistants and other licensed nursing staff. Demonstrates subject matter expertise regularly regarding medication, treatment, and patient care standards. Reduces inpatient readmissions by following up with discharged patients to ensure proper care transition by the Care Transition nurse, primary care physician, or appropriate home health agency.

Develops linkages needed between the hospital and key stake holders to provide timely support for patients post discharge. Improves the health status of post discharge patients. Maintains responsibility for enhancing efficiency and cost effectiveness by identifying opportunities to decrease costs, as applicable to the job.

Demonstrates initiative in managing the transition process. Manages the discharge post-acute care transition process for the organization. Works closely with the patient and/or family and coordinates activities with the multidisciplinary team including physicians, nursing and community resources.

Ensures patients’ adequate post acute care transition. Provides expert clinical care in general or specialty area.


Nurse Practitioner (NP) license in state of practice, r equired. Bachelor’s Degree in Nursing (BSN), or health/business administration and f ive years’ experience in a care management role, p referred. 20% – 40% travel required.

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