Job Description
About the Company 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 AI-driven clinical recommendations 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. About the Role Location: Remote - Focusing in on West Coast team members, folks in Mountain and Pacific time zones. West Coast Hours: 4:00 PM - 9:00 PM Pacific/Mountain (for Pacific/Mountain time zone candidates) Employment Type: Per Diem - Evenings/Weekends As a Per Diem Transition of Care Nurse Practitioner at Linea, you will serve as our frontline clinical expert focused on collaborating with ED teams to facilitate safe alternatives to hospitalization and after-hours patient support . This critical role positions you as the first responder when our active patients present to emergency departments, where you'll collaborate with ED clinical teams to develop creative solutions that help divert unnecessary readmissions. Drawing on your emergency medicine background, you'll communicate effectively with ED providers, understand their workflow, and work alongside our care navigators to arrange outpatient follow-up, coordinate PCP visits, facilitate medication monitoring, order repeat labs, and implement other problem-solving interventions that keep patients out of the hospital. Beyond Emergency Department support, you'll manage after-hours patient communications, responding to incoming texts and either resolving issues directly or triaging them to our daytime team. You'll review and share clinical recommendations for GDMT optimization and cardiorenal metabolic syndrome management with patients' prescribing teams—initiating faxes and phone calls during business hours or ensuring proper documentation for after-hours communication. Additionally, you'll handle new patient enrollment on our platform, initiating first contact, and setting up regular communication schedules with the daytime team. Responsibilities Emergency Department Admission Diversion & Intervention Partnering with emergency departments to prevent unnecessary admissions ED Clinical Collaboration: Respond immediately when active patients present to emergency departments; communicate directly with ED physicians, nurses, and providers to understand clinical presentations and develop alternative plans to admission Readmission Prevention: Work collaboratively with ED teams and patients to identify solutions that could prevent unnecessary hospitalizations, including arranging urgent outpatient follow-up, coordinating same-day or next-day PCP visits, facilitating medication adjustments, ordering repeat labs, and implementing other creative interventions Care Navigator Coordination: Partner closely with care navigators to implement follow-up plans, leveraging their support for scheduling, transportation coordination, and patient outreach while you drive the clinical decision-making Real-Time Problem Solving: Apply emergency medicine expertise to quickly assess situations, understand ED workflows, and communicate clearly with emergency providers to facilitate safe discharge plans After-Hours Patient Communication & Support Text Message Triage: Monitor and respond to all incoming patient texts during evening/early morning hours, providing clinical guidance, troubleshooting issues, or appropriately directing concerns to the daytime clinical team Problem Resolution: Address urgent patient concerns independently when appropriate or ensure seamless handoff to daytime staff for issues requiring extended follow-up Clinical Accessibility: Serve as the accessible clinical resource for patients during non-business hours, maintaining continuity of care and preventing escalation to emergency services GDMT & Cardiorenal-Metabolic Optimization Clinical Recommendations Review: Analyze evidence-based recommendations for guideline-directed medical therapy, cardiorenal metabolic syndrome management, and fluid optimization Provider Communication: Share GDMT recommendations with patients' prescribing teams through appropriate channels: During Business Hours: Initiate faxes AND phone calls to prescribing clinics to discuss recommendations directly After