If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered. Day - 08 Hour (United States of America) The Advanced Practice Provider (APP) plays a pivotal role in the Transitions of Care Program (TOC), a collaborative initiative between the Geriatrics Clinic and the Department of Aging and Adult Services. This position is dedicated to improving post-hospital transitions and reducing readmission rates for aging adults with multiple comorbidities and complex care needs who are at moderate to high risk for readmission and are discharging to home. Clinician support is essential to achieving the program’s goals of delivering high-quality patient care, preventing complications and readmissions, and generating cost-savings for the organization. Key responsibilities include: Providing comprehensive post-discharge care and care coordination for vulnerable older adults, ensuring a seamless transition from hospital, rehab, or skilled nursing facility to home. Delivering care virtually or in the patient’s home for individuals residing in San Mateo, Santa Clara, or Alameda counties. Supporting a value-based care model for Medicare Managed Care programs, serving all Medicare patients (excluding VA/Kaiser members). Engaging patients and caregivers in collaborative care planning, risk reduction strategies, and connecting them with appropriate resources to help prevent avoidable readmissions. Working closely with the TOC Medical Director, Nurse Manager, and Program Director to support program operations and outcomes. The APP provides both virtual and in-home visits, typically seeing multiple patients per day with travel between homes. Core clinical activities include conducting comprehensive post-discharge assessments (medical, functional, psychosocial, and environmental), monitoring recovery, and managing medications through thorough reconciliation and patient/caregiver education. The APP develops individualized care plans, coordinates with primary and specialty providers, facilitates follow-up appointments, and connects patients to community resources. They assess and mitigate risks such as falls, home safety concerns, and caregiver burden, intervening early to prevent complications. Accurate and timely documentation in the EHR, tracking of quality metrics, and effective communication with the care team are essential. The APP participates in interdisciplinary huddles and team meetings, provides emotional support to patients and families, and ensures a smooth transition at the end of patients'' 30-day TOC program enrollment period. **This is a Stanford Health Care job.** **A Brief Overview** The Nurse Practitioner (NP) functions under this Nurse Practitioner Job Description approved by the Interdisciplinary Practice Committee (IDPC). The NP provides routine are and management of the patient with acute and chronic complaints, in collaboration with the supervising physician, and through implementation of standardized procedures. Specific functions pertaining to the Service, Clinic or Department are established by the NP and his/her supervising physician(s), and approved by the appropriate medical and nursing administrators, the IDPC, the Credentials & Privileges Committee, the Stanford Hospital and Clinics (SHC) Medical Executive Committee and the SHC Board Credentials, Policies and Procedures Committee. This job description covers all classifications for NPs within the organization. All NPs must meet all elements of the Essential Functions, Qualifications, and Supervision. There is a voluntary Career Ladder for NPs who are interested in promotions for clinical expertise and contributions to the institution as well as the profession. Promotion is determined based on the Center for Advanced Practice Career Ladder Handbook. Here is a description of the various levels: Job Attributes: LEVEL I LEVEL II LEVEL III FLSA Status: Exempt Exempt Exempt Job Code: 400077 400169 400170 Requirement: LEVEL I: Entry level LEVEL II: Meets Career Ladder criteria for NP II LEVEL III: Meets Career Ladder criteria for NP III **Locations** Stanford Health Care **What you will do** + A. An NP may provide only those medical services which he/she is competent to perform, which are consistent with the NP’s education, training and experience, and which are performed under the supervision of a physician who is responsible for the patients cared for by that NP. + B. An NP shall consult with a physician regarding any task, procedure or diagnostic problem which the NP determines exceeds his/her level of competence or shall refer such cases to a collaborating physician. + C. Scope of Practice of the NP: + Evaluates and treats patients with acute, chronic complaints and health maintenance concerns related to specialty, according to written standardized procedures. [see Appendix A: Assessment & Management of Patients] + Obtains complete histories and performs pertinent physical exams with assessment of normal and abnormal findings on new and return patients, according to written standardized procedures. [see Appendix A Assessment & Management of Patients] + Performs or requests and evaluates diagnostic studies as indicated upon evaluation of the patient, according to written standardized procedures. [see Appendix A: Assessment & Management of Patients] + Administers, orders, furnishes and prescribes medications, according to written standardized procedures. [see Appendix B : Administering, Ordering, Furnishing or Prescribing of Drugs; Formulary Protocol] + Orders and collects specimens for routine laboratory tests, screening procedures and therapeutic procedures, including blood and blood products. + Orders physical therapy, occupational therapy, respiratory therapy, radiology examinations and nursing services. + Performs designated procedures after demonstrated competency, according to written standardized procedures where applicable. + Obtains informed consent, as indicated. + Initiates arrangements for hospital admissions and discharges and completes appropriate paperwork. + As directed by the supervising physician, enrolls patients in investigational studies approved by the Investigational Review Board (IRB), and orders the necessary tests and medications. [see Appendix B: Administering, Ordering, Furnishing or Prescribing of Drugs; Formulary Protocol] Medications that are not FDA-approved or are used for a non-FDA-approved indication (off-label use) require a patient-specific order in advance from the supervising physician. + After appropriate training, assists the supervising physician in the operating room. The RN First Assistant directly assists the surgeon and practices under the supervision of the surgeon during the intraoperative phase. The RN First Assistant must adhere to standardized procedures and not concurrently function as a scrub nurse. + Recognizes and considers age-specific needs of patients. + Effectively communicates and interacts with patients, families, staff and members of the community from diverse backgrounds. + Recognizes situations which require the immediate attention of a physician, and initiates life-saving procedures when necessary. + Facilitates the coordination of inpatient and outpatient care and services as needed. + Facilitates collaboration between providers and coordination of community resources. + Ensures compliance with legal, regulatory and clinical policies and procedures. + Participates in quality improvement initiatives. + Provides and coordinates patient teaching and counseling. + Other duties as assigned. **Education Qualifications** + Master’s or Doctoral degree in nursing from an accredited college or university. + Note: NPs hired prior to March 1, 2012 are not subject to this educational requirement. + Graduate of an NP program accredited by the National League of Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE). **Licenses and Certifications** + Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure and + NP - Nurse Practitioner and + NPF - NP Furnishing Number and + BLS - Basic Life Support and **These principles apply to ALL employees:** **SHC Commitment to Providing an Exceptional Patient & Family Experience** _Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery._ _You will do this by executing against our three experience pillars, from the patient and family’s perspective:_ + Know Me: Anticipate my needs and status to deliver effective care + Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health + Coordinate for Me: Own the complexity of my care through coordination **Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in** **all of** **its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.** Base Pay Scale: Generally starting at $89.01 - $117.94 per hour The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage. At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow. As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care. Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .