Saint Agnes Medical Providers, in partnership with Saint Agnes Health, is seeking an Advanced Practice Provider (NP or PA) to join our growing Post Discharge Clinic Clinic in Fresno, California. This position focuses on the management of patients transitioning from the hospital, emergency department, rehabilitation facility, or other acute care settings back into the community.

As a Post Discharge Clinic APP, you will play a critical role in improving care transitions, reducing avoidable hospital readmissions, and supporting recovery for patients with complex medical conditions, including heart failure (CHF), COPD, cardiovascular disease, and other chronic illnesses. Working alongside physicians, care managers, pharmacists, rehabilitation specialists, and primary care providers, you will deliver comprehensive, patient-centered care in a collaborative outpatient setting.

Key Responsibilities

• Conduct post-discharge evaluations and follow-up visits in person, virtually, or by telephone as clinically appropriate.
• Review discharge summaries, diagnostic results, medications, and care plans; perform medication reconciliation and address care gaps.
• Assess and manage patients recovering from acute illness, hospitalization, surgery, or rehabilitation stays.
• Order and interpret laboratory tests, imaging, and other diagnostics; prescribe medications and adjust treatment plans within scope of practice.
• Manage patients with chronic conditions such as heart failure, COPD, cardiovascular disease, and other complex medical needs.
• Provide patient and caregiver education focused on disease management, recovery, medication adherence, and prevention of readmissions.
• Coordinate care with primary care providers, specialists, home health agencies, rehabilitation services, and community resources.
• Document clinical care accurately and participate in quality improvement initiatives focused on transitions of care, patient outcomes, and readmission reduction.

Why Join Saint Agnes?

• Help shape and grow an innovative post-acute care program focused on improving patient outcomes and care transitions.
• Collaborate with an experienced multidisciplinary team dedicated to excellence in coordinated, value-based care.
• Opportunity to make a meaningful impact by reducing readmissions and supporting patients through recovery.
• Competitive compensation and comprehensive benefits package.
• Monday-Friday outpatient practice environment with a strong emphasis on teamwork, quality, and patient experience.