Transition of Care Nurse Practitioner - Heart Failure & Cardiorenal-Metabolic Disease Management

Linea is at the forefront of supporting patients during their most vulnerable times, particularly in the critical 90 days post-hospitalization. Our innovative care model integrates advanced remote monitoring, direct patient communication, and intelligent clinical decision support to reduce readmissions and improve outcomes. Join us in our mission to transform Heart Failure & Cardiorenal-Metabolic Disease management and deliver substantial cost savings for our healthcare partners.

Location: Remote - All U.S. time zones considered Employment Type: Full-Time, Salaried with Comprehensive Benefits As a Transition of Care Nurse Practitioner at Linea, you will serve as a comprehensive clinical expert managing the full spectrum of heart failure and cardiorenal-metabolic disease care for our enrolled patients. This dynamic role positions you as the clinical leader behind evidence-based care protocol execution and the frontline partner with emergency departments when patients experience acute concerns. You'll leverage your clinical expertise to review system-generated recommendations, optimize medication regimens, and manage fluid balance strategies while maintaining collaborative relationships with patients' established care providers.

Clinical Protocol Review & GDMT Optimization: Expert Clinical Review: Evaluate system-generated recommendations for GDMT optimization, fluid management, and diuretic therapy adjustments; apply your clinical expertise to approve, modify, or reject recommendations based on patient-specific factors and real-time data. Medication Optimization Leadership: Execute evidence-based medication strategies by coordinating with patients' prescribing providers through faxes, phone calls, and direct communication; use clinical judgment to determine timing and approach for each intervention. Cardiorenal-Metabolic Expertise: Lead comprehensive management of patients with complex heart failure, diabetes, and chronic kidney disease, utilizing your advanced clinical knowledge to execute multi-system care protocols. Gap Identification & Intervention: Leverage our intelligent evaluation system's analysis of patient histories to identify care gaps, then use your clinical judgment to prioritize and address these opportunities through evidence-based interventions. Emergency Department Partnership & Admission Prevention: ED Clinical Collaboration: Serve as the primary clinical contact when enrolled patients present to emergency departments; communicate directly with ED physicians, nurses, and providers to understand clinical presentations and partner on care planning. Admission Prevention Support: Work collaboratively with emergency teams to identify safe alternatives to hospitalization, including arranging urgent outpatient follow-up, coordinating same-day or next-day PCP visits, facilitating medication adjustments, ordering repeat labs, and implementing other interventions that support appropriate discharge planning. Real-Time Problem Solving: Apply emergency medicine expertise to quickly assess situations, understand ED workflows, and communicate clearly with emergency providers to facilitate safe care transitions when clinically appropriate. Patient Communication & Engagement: Complex Disease Management: Lead patient engagement for individuals with heart failure, diabetes, chronic kidney disease, and fluid management challenges.. Proactive Outreach: Conduct regular check-ins with high-risk patients to monitor symptoms, medication adherence, and early warning signs of decompensation. Provider Introduction: For newly enrolled patients, proactively contact prescribing providers to introduce Linea's services, establish collaborative relationships, and facilitate seamless care coordination. Data-Driven Clinical Operations: Clinical Decision Support: Review comprehensive patient data and system-generated insights to inform your clinical decision-making and identify intervention opportunities. Remote Monitoring Integration: Utilize advanced remote monitoring data to identify concerning trends, execute evidence-based interventions for medication adjustments, and respond to clinical status changes. Clinical Response Analysis: Analyze patient response patterns and use your expertise to modify care protocols and optimize outcomes. Platform Documentation: Maintain detailed records of clinical interventions, patient responses, care plan modifications, ED encounters, and provider communications. Collaborative Care Team Leadership: Provider Network Coordination: Maintain collaborative relationships with cardiologists, nephrologists, endocrinologists, primary care providers, and emergency department teams to ensure seamless execution of care protocols. Clinical Communication: Facilitate evidence-based recommendations to prescribing providers, supporting medication optimization decisions with clinical rationale and patient data through faxes, phone calls, and electronic communication. Interdisciplinary Coordination: Work with pharmacists, care navigators, and clinical team members to ensure comprehensive execution of care plans. Risk Stratification and Monitoring: Conduct comprehensive assessments using validated tools and your clinical expertise to guide protocol-based interventions.