Primary Care Ambulatory RN

Primary Care Ambulatory RN

The Primary Care Ambulatory RN serves as a clinical partner to MMG physicians and advanced practice providers, supporting patients across the spectrum of general primary care within the outpatient setting. This role emphasizes patient safety, continuity of care, telephone triage, and disease management.

The Ambulatory RN comprehensively assesses patient health status to support the development, execution, and evaluation of individualized and population-based care plans. This role utilizes clinical judgment, data, and evidence-based guidelines to drive high-quality cardiovascular care. Key dimensions of this position include care coordination, patient safety, quality outcomes, teamwork, patient education, and population health management.

Essential Duties and Responsibilities

Primary Care Population Management & Care Coordination

Serves as a primary RN resource for patients with acute and chronic conditions, including diabetes, hypertension, respiratory conditions, and routine primary care diagnosis.

Collaborates with physicians and advanced practice providers to develop, implement, and evaluate evidence-based care plans.

Monitors patients' clinical status, including symptoms, medication adherence, and response to treatment plans.

Identifies patients at increased risk for clinical deterioration and escalates care appropriately.

Coordinates care across the outpatient continuum, including specialists, and ancillary services.

Patient Assessment, Education & Engagement

Performs independent nursing assessments using strong clinical judgment and critical thinking skills.

Provides comprehensive patient and family education, including:

o Disease processes and treatment plans

o Medication regimens (e.g., antihypertensives, anticoagulants)

o Preventative health and lifestyle modifications

Delivers education during end-of-visit consultations, nurse visits, and telephonic outreach.

Engages patients in self-management and shared decision-making, promoting adherence and improved outcomes.

Clinical Operations & Symptom Management

Manages and triages incoming patient communication, including symptom calls and clinical advice requests, ensuring appropriate level of care and timely access.

Utilizes standardized workflows and protocols to support safe, efficient patient disposition (e.g., home care, same-day visits, emergency department, or escalation to provider).

Recognizes abnormal findings and communicates changes in patient condition to providers in a timely manner.

Conducts independent nurse visits as appropriate, including education, follow-up assessments, wound checks, and care plan reinforcement.

Conducts Primary Care Acute Care visits as appropriate, including IV fluid and medication administration (e.g., anti-emetics, NSAIDS, diuretics), patient education, and care coordination (e.g., diagnostic imaging, labs.).

Medication Management & Safety

Supports medication management in collaboration with providers, including refills, titration support, and adherence monitoring.

Performs medication reconciliation to reduce risk of adverse events.

Care Coordination & Resource Connection

Connects patients to supportive services, including:

o Care management / complex care programs

o Social work and community resources

o Health coaching and disease management programs

o Addresses barriers to care, including access to medications, transportation, and follow-up services.

Documentation, Communication & Compliance

Documents all patient assessments, interventions, and outcomes accurately in the electronic medical record.

Communicates effectively with providers and interdisciplinary team members to ensure continuity and safety of care.

Maintains patient confidentiality in accordance with HIPAA regulations.

Supports quality initiatives aimed at improving health outcomes, reducing unnecessary emergency department visits, inpatient admissions, and enhancing patient experience.

Education

Associate's Degree Nursing

BLS

Montage Values

Employees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.

Experience

A minimum of 3 years of practice as an RN (acute care experience preferred). Experience with electronic medical record documentation. Working knowledge of quality standards and evidence-based practice.

Requirements

California licensed Registered Nurse. Strong letters of recommendation (2).

Skills and Abilities

Strong interpersonal and communication skills

Patient-centric problem-solving skills

Critical thinking skills

Cypress Healthcare Partners