Registered Nurse - Chronic Care/Transition of Care

Registered Nurse - Chronic Care/Transition Of Care

Adelante Healthcare Roosevelt - Phoenix, AZ 85008

Position Type Full Time Category Health Care

Overview

The Registered Nurse (RN) will play a pivotal role in guiding patients and their families through the healthcare system. Their primary focus will be to provide compassionate, patient-centered care while acting as an advocate for those they serve. The RN will be a vital member of the multidisciplinary healthcare team, dedicated to delivering high-quality nursing services across various departments, including adult primary care, women's health, and pediatrics.

In this diverse role, the RN will engage with patients in a culturally sensitive manner, conducting thorough assessments of their health needs, performing essential clinical procedures, and facilitating comprehensive care plans. Collaboration with interdisciplinary team members will be crucial in ensuring seamless care integration and improving health outcomes for patients. By addressing the unique challenges faced by the community, the RN will help empower individuals with the education and resources necessary for managing their medical conditions effectively.

Every Adelante Healthcare employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected to work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism, and competence.

Our core values:

• Inclusion
• Nurture
• Service
• Purposeful
• Integrity
• Resilient
• Engaged

Qualifications

Essential skills and experience:

• Graduation from an accredited nursing program
• Licensed with the AZ State Board of Nursing
• License to be in good standing
• Two (2) to five (5) years of experience in a clinical setting
• Demonstrated application of Nursing Planning (Assessment, Nursing Diagnosis, Goals/Outcomes, Implementation, and Evaluation)
• Demonstrated understanding of clinical methods and techniques used in record-keeping systems
• Demonstrated ability in implementing the principles and practices of supervision
• Good working knowledge of Microsoft Office applications, including Outlook, Word, and Excel
• Must be able to write analytic reports integrating multiple data elements and perspectives
• Must be familiar with Adelante healthcare mission, vision, and core values and use them during patient care and collaboration with non-clinical and clinical teams
• Must be able to maintain confidentiality, privacy, and security of protected information
• Must possess excellent verbal and written communication skills, with the ability to communicate effectively with internal and external customers
• Travel to all health centers is required as needed
• Advanced computer efficiency in the Microsoft Office suite (Word, Excel, PowerPoint, Outlook) and experience in the Patient Management System
• Meet the organization's immunization requirement
• Valid Arizona driver's license and active automotive insurance
• Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and the Red Cross (cognitive and skills evaluations)
• Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations
• Participation in Community Events as required

Position Responsibilities

Patient Care Responsibilities

• Perform triage phone calls & Walk-in patients using approved procedures and resources for the adult primary care, women's health, and pediatric populations.
• Assist providers with procedures such as wound care, urinary catheterization, suture/staples removal, wart removal, lacerations, skin biopsy, abscess incision & drainage, toenail & skin tag removal, LEEP, Colposcopy, and Intrauterine Device Insertion (IUD).

• Perform EKG, Peak flow, spirometry, albuterol & oxygen treatments and document results in the electronic health record.

Clinical Collaboration

• Collaborate with the clinical team to review and act on Tasks/PTAs sent by providers.
• Collaborate with the FM/IM interdisciplinary team to assist with point-of-care testing including HbA1c, UA, HCGs, hemoglobin, Fecal Occult Blood Test, Lead screening, PKU, HIV and Strep.
• Support heath center staff with vaccine and medication administration, including NG-G-tube (Rota vaccine).
• Perform PPD placement, Flu and COVID testing.
• Support referral process as needed per AHC standing orders and procedures.
• Develop Self-Management Goals (SMGs) in collaboration with the patient to set up SMART (Specific, Measurable, Attainable, Realistic, Time-bound) goals that are patient-centered.
• Support troubleshooting/problem-solving by using critical thinking during complex situations.
• Support referral process as needed per AHC standing orders and procedure.
• Review and contact patients regarding normal & abnormal labs & diagnostics results.

Quality Improvement and Coordination

• Collaborate with the interdisciplinary team to improve the Uniform Data System (UDS) Quality Metrics.
• Collaborate with the integrated care team to improve Care Delivery Integration and closure of Healthcare Effectiveness Data & Information Set (HEDIS) care gaps of required Quality Metrics.
• Coordinate outreach efforts to high-risk patients and hospital discharge and admissions, including collaboration with health plans, hospitals, and skilled nursing facilities for transitional care.
• Assist with tasks/PTA messages about insulin titration for the diabetic population, which can include education and follow-ups.
• Identify barriers to care and social determinants of health by ensuring the PRAPARE survey has been collected.
• Support with High-Risk Prior Authorizations, Durable Medical Equipment (DME), and Short-Term Disability as needed.
• Work collaboratively with the clinical team to ensure compliance with Joint Commission, HRSA, and AHC standards.

Leadership and Accountability

• Provide leadership for collaboration and coordination of services, which includes defining the appropriate skill mix and delegation of tasks among licensed and unlicensed healthcare staff.
• RNs are fully accountable in all ambulatory care settings for all nursing services and associated patient outcomes provided under the direction of clinical providers.

Patient Education and Reporting

• Provide education and reporting STIs as needed for public health.
• Build relationships with external healthcare organizations and facilities in efforts to find additional resources to support patient care.

Administrative Responsibilities

• Obtain medical records, labs & diagnostics results as needed.
• Align role and responsibilities with Adelante Healthcare's mission, vision, core values policies, and procedures
• Ensure proper and complete documentation using approved templates in the electronic health record.
• Conduct medication reviews, reconciliation, and refills as needed

Evaluate clinical resources and support the development of new tools, forms, and procedures as needed.

• Participate in team meetings as needed.

Skills and Competencies

• Apply critical thinking and organizational skills in all tasks related to specialty and the organization's standards, including providing discharge instructions for patients.

• Enhance patient safety and the quality and effectiveness of care delivery, making sure to assess, set goals, implement, and evaluate professional nursing services per the Board of Nursing Scope of Practice and organizational standards.

Family Medicine (FM)/Internal Medicine (IM) RN:

• Collaborate on the performance of Medicare Wellness Visits by conducting assessments, completing surveys, reviewing patient's charts and documenting appropriately in the electronic health record by following established procedure and workflows.
• Provide direct nursing care to adult patients, including care coordination, patient education, triage, health assessments, medication administration, vaccinations, record management and quality improvement.
• Provide education to patients and their families on health management, disease prevention and wellness promotion.

Women's Health RN:

• Perform and interpret NSTs to monitor fetal well-being and pregnant patients, documenting results and communicating findings to the health care provider.