Transitions Medical Partners - Primary Care
Where
Transitions LifeCare
Raleigh, NC, United States
Description
The schedule for this role is Monday-Friday 8:30 am to 5:00 pm.
This role delivers direct patient care to individuals with acute, chronic, complex, and serious illness; supports continuity of care across settings; and collaborates closely with interdisciplinary teams. The Nurse Practitioner functions under the guidance of the Chief Medical Officer, Medical Director, referring physicians, and established plans of care, while practicing to the full scope of advanced practice nursing.
The position also supports provider, staff, and community education related to primary care, chronic disease management, pain and symptom management, serious illness communication, advanced care planning, and available services across the Transitions LifeCare continuum.
Responsibilities
Clinical Care – Primary Care
Provide comprehensive primary care services, including health maintenance, preventive care, and management of acute and chronic medical conditions
Perform patient assessments, physical examinations, and diagnostic evaluations
Diagnose and manage common primary care conditions (e.g., hypertension, diabetes, COPD, CHF, dementia, depression, and other chronic illnesses)
Order, review, and interpret diagnostic tests and laboratory studies
Prescribe medications and therapeutic interventions consistent with scope of practice, collaborative agreements, and regulatory requirements
Provide patient and caregiver education focused on disease management, health promotion, and self‑care
Participate in on-call rotation schedule with MD / Medical Director and team
Palliative Care and Hospice Services
Provide palliative care consultation and hospice visits in residential facilities, home settings, hospice inpatient facilities, and hospitals
Deliver pain and symptom management interventions based on established hospice and palliative care guidelines and standards
Conduct goals‑of‑care discussions, advance care planning, and shared decision‑making with patients and families
Provide attending provider services for hospice patients when assigned
Complete face‑to‑face visits to ensure compliance with Medicare/Medicaid hospice regulations
Attend Interdisciplinary Group (IDG) meetings as appropriate
Care Coordination and Collaboration
Collaborate with physicians, nurses, social workers, chaplains, care managers, and other interdisciplinary team members
Coordinate transitions of care across inpatient, outpatient, home‑based, and residential settings
Communicate effectively with referring providers, facility staff, and community partners to ensure continuity and quality of care
Documentation, Quality, and Education
Document accurately and timely in the patient medical record in accordance with federal, state, regulatory, and agency requirements
Assist with data collection, quality metrics, forms, and outcome evaluation tools for primary care, palliative care, and hospice programs
Work with the Chief Medical Officer and Associate Medical Director to educate hospital staff, residential facility staff, and community physicians on:
Primary care integration
Chronic disease management
Palliative care principles
Pain and symptom management
End‑of‑life communication
Available Transitions LifeCare programs
Participate in on‑call rotation as required by contract agreement
Perform other duties as assigned by supervisor
Expectations
Demonstrate professionalism, compassion, respect, teamwork, and accountability in all interactions
Adhere to all Transitions LifeCare policies, procedures, and organizational guidelines
Deliver care in accordance with ACHC Standards and Medicare Conditions of Participation as applicable
Comply with all state and federal laws, regulations, and professional standards within defined scope of practice
Communicate concerns, risks, or quality/safety issues promptly to leadership
Requirements
Nurse Practitioner with current North Carolina license
Minimum 3 years of clinical experience preferred
Experience in primary care, internal medicine, geriatrics, hospice, palliative care, and/or home health preferred
ACHPN certification preferred
Maintain continuing education requirements for Nurse Practitioner licensure
Knowledge of reimbursement sources, Medicare regulations, licensing laws, and accreditation standards
Computer proficiency preferred
Current CPR certification
Valid North Carolina Driver’s License, active automobile insurance, and access to reliable transportation
Environmental Factors
Potential exposure to bloodborne pathogens
Possible exposure to communicable diseases or bodily fluids
Apply
Attn: Heather Boykin
E-mail: [email protected]