Overview of the Position

We are seeking an experienced and confident Nurse Practitioner to support a temporary, targeted initiative aimed at reducing unnecessary hospitalizations and improving care transitions for seniors and complex patients in Edmonton.

This role is embedded within a collaborative, community-based model that partners closely with social work, transition services, and community providers to proactively identify and support individuals at risk of hospital admission or readmission.

This position offers a unique blend of:

- Clinic-based care
- Community and in-home visits (flexible)
- Virtual care delivery

You will manage a small, well-supported patient roster (approximately 100–150 patients), focusing on proactive, preventative care, chronic disease management, and stabilization of high-risk patients to support safe community living.

In addition to clinical care, this role contributes to system navigation, care coordination, and program development within an innovative model designed to improve patient outcomes and reduce strain on acute care services.

RESPONSIBILITIES

Clinical Care

- Provide comprehensive assessment, diagnosis, and treatment within Nurse Practitioner scope of practice
- Identify high-risk patients and implement proactive care plans to prevent deterioration
- Manage complex and chronic conditions with a focus on stabilization and prevention
- Prescribe medications and monitor ongoing therapies
- Deliver longitudinal care, including follow-up and ongoing coordination
- Promote health, prevent disease, and support chronic disease management
- Provide care across settings including clinic, community, and patients’ homes
- Intervene early to reduce avoidable emergency department visits and hospital admissions

Care Coordination & Transitions

- Collaborate with social workers, transition teams,



and hospital discharge staff
- Support smooth transitions from hospital to community-based care
- Address social determinants of health (e.g., housing, supports, access to services)
- Connect patients with appropriate community resources and supports
- Act as a key clinical resource to prevent readmissions and ensure continuity of care

Collaboration & Team Engagement

- Work collaboratively with interdisciplinary team members, community providers, and caregivers
- Participate in team meetings and organizational initiatives
- Foster professionalism, accountability, and continuous learning
- Follow organizational policies, procedures, and clinical standards
- Contribute to quality improvement and program evaluation activities

Community Engagement

- Build and maintain relationships with community partners and agencies supporting seniors
- Promote programs and services through outreach and presentations
- Liaise with healthcare providers and community organizations involved in patient care

Evaluation & Program Development

- Support evaluation of program outcomes, including reducing hospital utilization
- Contribute to program development and service improvement strategies
- Participate in quality improvement initiatives aligned with system goals

Continuing Education

- Maintain up-to-date knowledge of best practices in seniors’ health and community-based care
- Maintain current NP licensure through CARNA




- Maintain current CPR and First Aid certifications

QUALIFICATIONS

- Master’s Degree in Nursing and Nurse Practitioner licensure in Alberta (Adult or Family All Ages)
- 2–5 years of experience in a primary care or community-based setting
- Strong experience managing complex, high-risk, or vulnerable patient populations
- Experience in care transitions, hospital discharge planning, or community-based care models is an asset
- Additional certifications (e.g., geriatrics, diabetes education, palliative care) are considered assets
- Knowledge of evidence-based primary care practices, with emphasis on prevention and seniors’ health
- Police Information Check including Vulnerable Sector required

SKILLS AND EXPERIENCE

- Strong clinical judgment with a focus on risk identification and prevention
- Experience developing community linkages and stakeholder relationships
- Knowledge of Continuous Quality Improvement processes
- Excellent communication and organizational skills
- Ability to work independently in community settings and collaboratively within a team
- Flexible, adaptable, and solutions-oriented
- Proficiency with Electronic Health Records and digital tools

HOURS OF WORK

Full time or part-time position depending on program needs and candidate availability.Flexible scheduling, while ensuring clinic and program coverage.

Pay: $115.00-$135.00 per hour

Benefits:

- Casual dress
- Flexible schedule

Ability to commute/relocate:

- Edmonton, AB: reliably commute or plan to relocate before starting work (required)

Experience:

- Nurse Practitioner : 2 years (required)

Licence/Certification:

- Current NP license through CARNA (required)

Location:

- Edmonton, AB (required)

Work Location: Hybrid remote in Edmonton, AB

📌 Primary Health Care Nurse Practitioner (Edmonton)
🏢 Care2Talk Technologies
📍 Edmonton