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 You’ll 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
Collaboration & Program Support
- 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
- Master’s Degree in Nursing with active Nurse Practitioner licensure (Adult or Family All Ages) in Alberta, CA
- 5–7 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.
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