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Westside Family Healthcare is a nonprofit organization that provides high quality primary medical care without regard to ability to pay. The Ambulatory Care Nurse (RN) is an on-site nurse RN serving as an integral member of the patient care team, supporting assigned care teams by managing high and rising risk patients, coordination services throughout the continuum of care and serves as the in-office nurse. The Ambulatory Care Nurse RN supports patients by facilitating implementation of the prescribed medical treatment plan through patient-centered education of disease processes and wellness opportunities and through patient self-management skill development.
Job Responsibility:
Manage a caseload of patients identified as at risk for health deterioration, sentinel events and/or poor outcomes using the nursing process and established protocols/workflows
Ongoing evaluation of care coordination efforts by measuring interventions effectiveness and fostering a continuous improvement mentality
Partners with the patient and family, the primary care provider, and other team members to implement an interdisciplinary plan of care
Participates in daily huddles with the Clinical Operations team, and other team meetings/trainings as scheduled
Proactively and continuously reviews patient medical records to identify any care needs requiring intervention or follow up during patient interactions
Works with patients and families to ensure both medical and psychosocial needs are met in order to promote health and well-being and to identify any barriers that inhibit the patient from adhering to the prescribed plan of care
Educates patient/family about medical conditions (existing or newly diagnosed) to assist them in appropriate self-management
Proactively incorporates lifestyle improvement opportunities and preventative care into patient interactions, empowering patients to reach their individual health goals
Assesses and documents progress towards goals based on provider’s plan of care
utilizing clinical judgment, established protocols, review of patients’ self-monitory tools and trends in clinical data (i.e., HbA1c, LDL, BP)
Promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk
Provides ambulatory care support as a member of the care team, which may include, but is not limited to walk-in and/or telephone triage utilizing established protocols
Proactively advocates for patient care issues to ensure overall quality and adherence to provider’s plan of care
ensuring care is sensitive to each specific patient’s needs
Participates in quality improvement activities and initiatives
Other duties as assigned
Maintains compliance with all professional and organization requirements to meet position standards
Requirements:
Graduate of an accredited nursing program with an associate degree in Nursing
Active RN licensure in the State of Delaware (or compact state) with no restrictions or disciplinary action
Current BLS certification
Active Ambulatory Care Certification (AMB-BC) – must commit to obtaining within 1 year of hire