Job Description

Sign On Bonus Eligible

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$53.00 - $82.08

Schedule:

Full Time

Shift Hours:

8 Hour employee

Department:

Ambulatory Patient Advance Access

Job Objective:

Responsible for coordinating patient-centered care across the outpatient continuum, with a focus on high-risk and complex patient populations. Collaborates closely with providers, interdisciplinary teams, and community resources to support high-risk and complex patients through proactive outreach, comprehensive assessment, care planning, and transition management. Aims to improve clinical outcomes, enhance patient experience, and reduce unnecessary utilization.

Education:

Required: Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing

Licensure/Certification:

Required: California Registered Nurse (RN) licensure

Preferred: Certification in Case Management

Experience:

Required: Three (3) years of experience as a RN in an ambulatory/clinic or case management setting

Reports To: Clinical Manager or Director

Supervises: N/A

Ages of Patients: Pediatric, Adolescent, Adult, Geriatric

Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to analyze situations accurately and takes effective action, Ability to communicate with patients, healthcare professionals, and staff to ensure clear and accurate exchange of information, Ability to work independently and exercises a high degree of initiative, judgment and discretion, Knowledgeable about notices of non-coverage/denial letters to patients including Medicare/HSAG, federal and state and guidelines, Knowledgeable about regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition, Knowledgeable about the various health care delivery systems and payer prior approval requirements, Self-motivated, self-starter, and able to organize efforts around helping clients have a positive experience, Strong clinical and critical thinking skills and ability to establish and carry out complex plans of care for key diagnoses, Written and verbal communication skills

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.

2. Establishes rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals; integrates an awareness of cultural factors in the patient/family interview process and elicits clinically relevant cultural information.

3. Collaborates with the physician, patient and interdisciplinary team to establish a comprehensive plan of care to appropriately address clinical milestones.

4. Communicates plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team; facilitates communication between the physician, interdisciplinary team, patient and family.

5. Gathers sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner.

6. Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes; modifies plan of care as patient/family needs change to accomplish goals established in the plan of care.

7. Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed; communicates resulting decisions to patient/family, physicians and members of healthcare team, according to regulatory guidelines and hospital policies.

8. Identifies opportunities to improve care/service; assists in development and implementation of care performance improvement plans based upon analysis of patterns and trends identified from data collection and observations.

9. Documents all care management assessments and interventions.

10. Ensures that the care plan is updated as appropriate, through clinical progression of the patient toward clinical milestones updating the team and patient and family accordingly.

11. Refers to Social Worker or Discharge Planner for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up; consults with other members of the interdisciplinary team (physical therapy, pharmacy, etc.) to provide safe discharge as appropriate.

12. Ensures that any information appropriate to facilitate continuity of care post discharge is communicated to post-acute provider via discharge paperwork or via phone per departmental documentation guidelines.

13. Develops strong relationships with community health resources; develops, maintains and provides community resource information to patients.

14. Helps patients obtain a PCP (Primary Care Physician) and affordable discharge medications and resources as necessary.

15. Ensures appropriate follow-up appointments are made and patient is knowledgeable about post discharge activities.

16. Monitors and manages clinical outcomes and intervenes on issues that have the potential to impact quality.

17. Performs proactive outreach to high-risk patients, including those with frequent ED visits, hospitalizations, or chronic conditions.

18. Coordinates transitions of care (e.g., post-ED, post-inpatient, SNF discharges) to ensure timely follow-up and prevent readmissions.

19. Collaborates with primary care providers, specialists, and interdisciplinary teams to align care plans and close care gaps.

20. Facilitates referrals to internal programs (e.g., social services, behavioral health, pharmacy support) and external community resources.

21. Educates patients and caregivers on disease management, medication adherence, and navigating the healthcare system.

22. Identifies and escalates clinical concerns or barriers to care to appropriate providers or leadership.

23. Participates in interdisciplinary case conferences, team huddles, and quality committees.

24. Utilizes data, registries, and dashboards to prioritize outreach and measure effectiveness of interventions.

25. Assists with advance care planning discussions and long-term care planning when appropriate.

26. Embraces professional governance philosophy and demonstrates support through active participation and engagement.

27. Performs other duties as assigned.