Transition of Care Registered Nurse

Job Details Job Location: Adelante Healthcare West Phoenix - Phoenix, AZ, Salary Range: Undisclosed Position Summary The Transition of Care (TOC) Registered Nurse is responsible for facilitating seamless transitions for patients between healthcare settings. This role involves comprehensive patient assessments, care coordination, patient education, and strict adherence to regulatory requirements from HRSA, Arizona state regulations, and The Joint Commission, ensuring high-quality care for our underserved population. This position is essential to Adelante’s team-based primary care medical home model of care, which supports coordinated, patient-centered, comprehensive healthcare for all. This role will perform work primarily remote and occasional travel to health centers or company facilities may be required. Expectations Every Adelante 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. 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 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 Two (2) to five (5) years of experience in a clinical setting 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 Nonessential Skills and Experience Electronic Health Record experience; NextGen experience a plus Bilingual (Spanish/English), preferred Position Responsibilities / Essential Patient Care Responsibilities Conduct comprehensive initial and ongoing assessments of patients' medical and behavioral health needs during transitions from inpatient to outpatient care or between service providers. Support transition of care (TOC) through coordination of continuity of patient care with internal and external healthcare organizations and facilities, such as referrals to outside specialties and ongoing two-way communication between providers and care teams. Engage patients actively in their care processes, promoting self-management, health literacy, and wellness strategies. Perform medication reconciliation during transitions, identifying discrepancies and ensuring a complete review of medication lists. Collaborate with healthcare providers to recommend appropriate pharmacological therapies based on clinical assessments and evidence-based practice. Coordinate outreach efforts to high-risk patients and hospital discharge and admissions. Educate patients about their medications, including indications, adherences, and potential side effects. Review and act on care team tasks and inbox messages. Identify barriers to care and social determinates of health. Perform medication refills, prior authorizations, and referrals. Facilitate patient care based upon approved standing orders and protocols. Clinical Collaboration Actively support the referral process in accordance with AHC policies and procedure and standing orders, ensuring timely and efficient patient transitions post hospital discharge. Partner with patients to develop Self-Management Goals (SMGs) framed within the SMART criteria (Specific, Measurable, Attainable, Realistic, Time-bound). This approach fosters patient-centered care by empowering individuals to take an active role in their health management. Utilize critical thinking skills to troubleshoot and problem-solve during complex situations, ensuring the appropriate and effective solutions are implemented to address patient needs. Work collaboratively with an interdisciplinary team, including medical and behavioral health providers, case managers, integrated health staff and community health workers, to enhance care coordination and improve patient outcomes. Participate in regular case reviews and interdisciplinary team meetings to discuss complex patient needs and strategize on streamlined care transitions. Reviews and interprets laboratory results, providing critical insights and recommendations to the clinical team to guide decision making and tailored interventions for each patient’s care post hospitalization. Work collaboratively with the Transition of Care Program Manager, clinical team on data collection, health outcomes reporting, and clinical audits. Participate actively in programmatic evaluations that assess effectiveness and drive continuous improvement in patient care initiatives. Quality Improvement, Care Coordination and Regulatory Compliance Collaborate with the interdisciplinary team to improve the Uniform Data Contribute to quality improvement initiatives to enhance the transitions of care process, emphasizing patient safety, satisfaction, and regulatory compliance. Collect and analyze data related to patient outcomes and participate in developing strategies for quality enhancements in line with HRSA and Joint Commission standards. Maintain accurate and timely documentation of patient assessments, individualized care plans, and progress notes within electronic health records (EHR), adhering to legal and organizational standards. Thoroughly document all patient interactions, care recommendations, and follow-up plans to meet HRSA, state, and Joint Commission requirements Ensure compliance with the Health Resources and Services Administration (HRSA) guidelines, Arizona state regulations, and The Joint Commission standards. Stay updated on relevant policies impacting medical and behavioral health care delivery and documentation processes specific to FQHCs. 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 for their practice, maintaining high standards of care and ethical responsibility in all interactions and clinical decisions. Patient Education and Reporting Foster and maintain relationships with external healthcare organizations and facilities to identify and secure additional resources that support patient care initiatives and enhance service delivery. Conduct through patient assessments to develop individualized education plans tailored to meet specific patient needs and learning styles. Provide education and emotional support to patients and their families regarding care plans, treatment options, and available community resources through Adelante health Care. Empower patients by equipping them with the knowledge necessary to engage effectively in their care journey. 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. Participate in team meetings as needed. Skills and Competencies Apply critical thinking and organizational skills in all tasks related to TOC and the organization’s standards. 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. Additional Duties and Responsibilities Other duties as requested or assigned Patient Centered Medical Home (PCMH) and Integrated Care Team (ICT) All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team-based model to promote wellness and improve health outcomes. Adherence to Compliance and Code of Conduct All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Code of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation. Physical Demands and Work Environment The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Work environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic area. In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630, if the essential functions of this position cannot be performed satisfactorily by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization. #J-18808-Ljbffr Adelante Healthcare