Transitional Care Advanced Practice Provider (NY RBE)

Company: Oak Street Health
Location: New York
Posted on: June 1, 2025

Job Description:

Company: Oak Street HealthTitle: Transitional Care Advanced Practice Provider (APP)Location: New York (Queens, Brooklyn, Long Island, Bronx)Role DescriptionThe Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in delivering in-home support and care following adverse events, which include inpatient admissions. APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up. Provider teams enjoy easy access to clinical support from peers and medical directors and use best in class population health data to support patients when they need it most.Core Responsibilities

• 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 assignedWhat are we looking for
  • Genuine passion for reaching vulnerable patients
  • Strong clinical skills focused on older adults with complex disease states
  • Comfort navigating visits in patient homes
  • Demonstrated ability to collaborate effectively in a team setting
  • Willingness to learn and be accountable for visit documentation and workflows
  • Excellent communication, follow-up, teamwork, and problem-solving skills
  • Desire to be a part of a fast-paced, innovative, quality-driven organizationRequired Qualifications
    • 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 requiredWhat does being Oaky look like?
      • Radiating positive energy
      • Assuming good intentions
      • Creating an unmatched patient experience
      • Driving clinical excellence
      • Taking ownership and delivering results
      • Being relentlessly determinedWhy Oak Street Health?Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.Oak Street Health Benefits:
        • 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 advancementOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health
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Keywords: Oak Street Health, Yonkers , Transitional Care Advanced Practice Provider (NY RBE), Other , New York, New York