Job Title

Nurse Practitioner Community Health & Care Transitions Job Title: Nurse Practitioner Community Health & Care Transitions Location: Edmonton, AB (Clinic, Community, and Virtual) Pay Rate: $46$62/hour (based on experience) Duration: Assignment through March 2027 Schedule: Full-Time or Part-Time (Flexible; On-Call Required) Summary We are seeking an experienced Nurse Practitioner to support a targeted initiative focused on reducing hospitalizations and improving care transitions for seniors and high-risk patients. This role operates within a collaborative, community-based care model, working closely with social work, transition services, and community providers. You will manage a focused patient roster, delivering proactive, preventative care across clinic, home, and virtual settings. This position offers a unique opportunity to combine direct patient care with care coordination and program development to improve outcomes and reduce strain on acute care systems. What Youll Do Clinical Care - Provide comprehensive assessments, diagnosis, and treatment within scope of practice - Identify high-risk patients and implement proactive care plans to prevent hospitalization - Manage chronic and complex conditions with a focus on stabilization and prevention - Prescribe medications and monitor ongoing therapies - Deliver longitudinal care including follow-ups and care coordination - Provide care across clinic, community, and in-home settings - Support early interventions to reduce emergency visits and hospital admissions Care Coordination & Transitions - Collaborate with social workers, transition teams, and hospital discharge teams - Support smooth transitions from hospital to community-based care - Address social determinants of health impacting patient stability - Connect patients with appropriate community resources and services - Act as a key contributor in reducing readmissions and improving continuity of care - Work closely with interdisciplinary teams, caregivers, and community providers - Participate in team meetings and organizational initiatives - Contribute to program development, evaluation, and quality improvement efforts - Maintain compliance with organizational policies and clinical standards Community Engagement - Build relationships with community partners supporting seniors and vulnerable populations - Support outreach efforts, presentations, and awareness of available services - Collaborate with healthcare providers and external organizations involved in patient care What You Bring - Masters Degree in Nursing with active Nurse Practitioner licensure (Adult or Family All Ages) in Alberta, CA - 57 years of experience in primary care or community-based healthcare settings - Strong experience managing complex, high-risk, or vulnerable patient populations - Experience with care transitions, discharge planning, or community care models - Strong clinical judgment with a focus on prevention and risk identification - Excellent communication, organization, and collaboration skills - Ability to work independently in community settings and as part of a multidisciplinary team - Proficiency with electronic health records and digital tools Bonus Points If You Have - Additional certifications in geriatrics, diabetes education, or palliative care - Experience in community outreach and stakeholder engagement - Familiarity with continuous quality improvement (CQI) initiatives - Experience supporting seniors health programs or population health initiatives TCWGlobal is an equal opportunity employer. We do not discriminate based on age, ethnicity, gender, nationality, religious belief, or sexual orientation. #J-18808-Ljbffr