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Under the direction of the physician. The Nurse Practitioner (NP) will serve as a clinical leader in the Post Acute Care Clinic (PACC), managing care transitions and follow-ups for patients recently discharged from acute care settings. Working collaboratively with physicians, hospitalists, home health agencies, skilled nursing facilities (SNFs), and other post-discharge providers. The NP will ensure continuity of care, reduce avoidable readmissions and promote patient recovery and satisfaction's.

+ Evaluate and manage medical needs for patients discharged from inpatient settings within 2–7 days post-discharge. Conduct comprehensive post-discharge assessments, medication reconciliation, diagnostic follow-up, and care coordination. Collaborate with discharge planners, case managers, and ancillary providers (SNFs, IRFs, HHAs) to ensure timely interventions. Order diagnostic tests, interpret results, and adjust treatment plans accordingly. Identify red flags and escalate care to appropriate specialists or the emergency department when clinically necessary. Deliver care that complies with Medicare Transitional Care Management (TCM) guidelines and documentation standards. Serve as a clinical resource to PACC medical assistants (CMAs), front desk personnel, and referral teams. Maintain up-to-date electronic health records, progress notes, and billing documentation according to One Content and Paragon note protocols. Actively participate in quality improvement initiatives and performance reviews related to readmission reduction and patient outcomes.

Graduate of an accredited Nurse Practitioner program; Master’s or Doctoral degree in Nursing

Minimum of 1 year experience in post-acute care, hospital medicine, internal medicine, or emergency medicine Preferred experience in transitional care management or case coordination

Current, valid Alabama RN License and certificate to practice as a Nurse Practitioner as issued by the Alabama Board of Nursing. BLS required. Alabama Controlled Substance Certificate Federal DEA Registration (under physician’s clinic registration if applicable) BLS (required); ACLS (preferred)