Primary Care Ambulatory Registered Nurse - Montage Medical Group

Montage Health

1d•$73 - $97

About The Position

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.

Requirements

Associate’s Degree – Nursing
BLS
California licensed Registered Nurse
Strong letters of recommendation (2)
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
Strong interpersonal and communication skills
Patient-centric problem-solving skills
Critical thinking skills
Epic clinical documentation
Ability to effectively collaborate across a multidisciplinary care team

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: Disease processes and treatment plans Medication regimens (e.g., antihypertensives, anticoagulants) 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: Care management / complex care programs Social work and community resources Health coaching and disease management programs
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