Transitional Care Advanced Practice Provider (APP)

• 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 Street's electronic medical record
• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting
• Other duties, as assigned

• 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

Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve

• 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