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

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

• 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.

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