Job Description

Tiburcio Vasquez Health Center is a non-profit community health center that is dedicated to promoting the health and well-being of our community by providing accessible, high-quality care by integrating primary care, dental care, WIC support, mental health counseling, community health education, and more.

The Care Transitions Nurse, RN is part of a patient-centered team focused on coordination of care of patients in transition between the hospital and primary care setting. Primary responsibility include communication with hospital based and health plan based care teams and the site based clinical teams to coordinate patient transitions between levels of care. Under the general direction of the Hospital Discharge Coordinator, and in consultation with the CMO and COO, performs nursing care, including evaluation of medical needs for drop-in and telephoning patients, immunization administration, and oversight. The Care Transitions Nurse, RN will promote and restore patient’s health by providing, delegating, evaluating and coordinating comprehensive professional nursing care for patients of all ages, genders, cultures, and backgrounds. As a patient advocate, the Care Transitions Nurse, RN will also provide physical and psycho-social support to patients, their friends and families. The Care Transition Nurse may oversee clinical care as compatible with their licensure including monitoring of duties performed by MA staff.

This is a full-time position working 40 hours per week, typically Monday through Friday with periodic Saturday hours.

Compensation: $86,174.40 - $94,928.00, depending on experience.

Responsibilities:

• Maintains accurate tracking list of TVHC hospitalized adults from all local hospitals.
• Maintains access to the established list of high risk patients through health plan portal or other confidential site.
• Communicate clearly with TVHC patients about care plans. Ensure timely and appropriate hospital follow up and medical appointments.
• Notify TVHC staff as appropriate when patients are admitted to local hospitals.
• Review hospital discharge plan and notify primary care providers and/or Hospital Discharge Coordinator of important medical and social issues during hospitalization.
• Coordinate with Hospital Discharge Coordinator and Care Transitions CHW to organize, track, and report data.
• Represent TVHC in Care Transitions work group meetings with outside agencies.
• Provide quarterly statistics report to Sutter staff for all Care Transitions programs.
• Supports TVHC staff located at Eden Hospital, and aid staff in effective communication with hospital staff and patients.
• Initiate referrals for TVHC patients who qualify for additional home health services after hospitalization to include TVHC and community programs.
• Provides nursing services including: administration of medication and injections to patients as directed by the healthcare provider; immunizations; referrals to other providers and community health resources; and health instruction to patients or following examinations.
• Performs encounter forms and completes electronic health record entries (EPIC) for appropriate nurse-visits (e.g., health status checks, early urine pregnancy tests, medication administration).
• In coordination with MA staff, assists Healthcare Provider with in-clinic examination and procedures as appropriate.
• Performs patient chart updates during pre-visit prep, including reconciliation of medication list; including name(s) of medications, dosages, frequency, duration, and start date.
• Obtain medical report from outside healthcare providers (e.g., Specialty, Pharmacy), facilitation of communication to healthcare provider.
• In the capacity of patient advocate, assesses the learning needs of patients, develops and implements patients’ education as appropriate. Acts as a resource and contact person for patients.
• Obtain patient history for unscheduled patients arriving to the clinic as needed. Provide clinical support for patient calls as appropriate to scope. Performs assessment data collection and documents subjective data (Chief Complaint) and objective data (e.g., vital signs/weight). Reviews basic health history information for patients. Collaborates with Registered Nursing and Healthcare Provider to meet patient care needs.
• Visit patients in their homes and other ambulatory settings (i.e. skilled nursing facilities, post-acute rehabs, etcs.) as part of the Care Transitions program
• Attends general and medical staff meetings and participates in quality improvement projects.
• Assist the Chief Medical Officer and/or Chief Operations Officer on matters relating to nursing practices and participates in development of policies and protocol for patient care. Assist in the performance appraisals of personnel through documentation and input to the COO.
• Performs all duties and services in full compliance of TVHC’s Service Excellent Standards.
• Performs all duties necessary for successful EHR/EPM entries and maintenance of patient/client records.
• Performs other related duties as may be assigned by Hospital Discharge Coordinator, COO and/or CMO.

Requirements

• Current, valid California Registered Nurse license.
• Valid Cardiopulmonary Resuscitation Card (CPR).
• Minimum 1-year experience as RN, in an outpatient clinic preferred.

Qualifications:

• Excellent communication skills at level necessary for taking patients’ medical histories, understanding provider and supervisor instructions, and for accurately documenting patients’ medical information. Ability to effectively communicate with patient population and staff while demonstrating a high degree of diplomacy and tact.
• Intermediate to advanced computing and phone skills.
• Bilingual in English/Spanish or language(s) other than English strongly preferred.
• Working knowledge of “Universal Precautions” and demonstrated professionalism at all times.
• Ability to multi-task and work effectively in a high-stress and fast-moving environment.
• Possess a thorough understanding of the importance of confidentiality and non-disclosure according to the general standards set forth by HIPAA.
• Culturally sensitive and demonstrated ability and effectiveness working with ethnically diverse populations.
• Willingness to work evenings and/or weekends; demonstrates flexibility in regards to job duties and assignments.
• Ability to travel to designated locations as needed and as directed by supervisor

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and expectations required of the position.

Benefits

We offer excellent benefits including: medical (100% paid co-payments, premiums, etc.), dental, vision (including dependent and domestic partner coverage), generous paid leave benefits including holidays, Flexible Spending Accounts, retirement plans with an Employer match, tuition reimbursement, monthly treats, pet insurance, and more.

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