Transition of Care Registered Nurse

ADELANTE HEALTHCARE INC•Phoenix, AZ

5d•Remote

About The Position

The Transition of Care (TOC) Registered Nurse facilitates seamless patient transitions between healthcare settings through comprehensive assessment, care coordination, patient education, and compliance with HRSA guidelines, Arizona regulations, and The Joint Commission standards. The role supports Adelante Healthcare’s team-based primary care medical home model and its coordinated, patient-centered care for underserved communities. Work is performed primarily remotely, with travel to health centers or company facilities as needed. The nurse assesses patients’ medical and behavioral health needs, coordinates with internal and external providers, supports referrals and follow-up after hospital admissions and discharges, reconciles medications, and helps patients build self-management skills. The role collaborates with an interdisciplinary team, participates in case reviews and quality improvement activities, interprets laboratory results, and maintains accurate documentation in the electronic health record. The RN also provides leadership in coordinating services and delegating tasks, while remaining accountable for nursing practice and patient care. The position requires an accredited nursing program graduate with an Arizona nursing license in good standing, two to five years of clinical experience, CPR and AED certification, a valid Arizona driver’s license, and a Level One Fingerprint Clearance Card for specialty behavioral health locations. Microsoft Office proficiency, patient management system experience, strong communication and analytical skills, and the ability to travel to health centers as needed are also specified. Spanish/English bilingual ability and NextGen experience are preferred.

Requirements

Graduation from an accredited nursing program.
Arizona State Board of Nursing license in good standing.
Two to five years of experience in a clinical setting.
Demonstrated application of the nursing process: assessment, nursing diagnosis, goals/outcomes, implementation, and evaluation.
Understanding of clinical methods and techniques used in record-keeping systems.
Demonstrated ability to implement principles and practices of supervision.
Good working knowledge of Microsoft Office applications, including Outlook, Word, and Excel; advanced efficiency in Microsoft Office, including PowerPoint, is also specified.
Experience with a Patient Management System.
Ability to write analytical reports integrating multiple data elements and perspectives.
Ability to maintain confidentiality, privacy, and security of protected information.
Excellent verbal and written communication skills and ability to communicate effectively with internal and external customers.
Ability to use Adelante Healthcare’s mission, vision, and core values in patient care and collaboration with clinical and non-clinical teams.
Ability to travel to all health centers as needed.
Meet the organization’s immunization requirement.
Valid Arizona driver’s license.
CPR and AED certification for the Health Care Professional through courses following American Heart Association or Red Cross guidelines, including cognitive and skills evaluations.
Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations.
Critical thinking and organizational skills, and ability to assess, set goals, implement, and evaluate professional nursing services in accordance with the Board of Nursing Scope of Practice and organizational standards.
Ability to participate in community events as required.

Nice To Haves

Electronic Health Record experience; NextGen experience is a plus.
Bilingual Spanish/English ability.

Responsibilities

Conduct comprehensive initial and ongoing assessments of patients’ medical and behavioral health needs during transitions between care settings.
Coordinate continuity of care with internal and external healthcare organizations, including referrals and two-way communication between providers and care teams.
Engage patients in self-management, health literacy, and wellness strategies; develop SMART self-management goals with patients.
Perform medication reconciliation, identify discrepancies, educate patients about medications, and collaborate with providers on pharmacological therapies based on clinical assessments and evidence-based practice.
Coordinate outreach to high-risk patients and support hospital admission and discharge transitions.
Review and act on care team tasks and inbox messages; identify barriers to care and social determinants of health.
Perform medication refills, prior authorizations, and referrals, and facilitate care under approved standing orders and protocols.
Collaborate with interdisciplinary medical and behavioral health providers, case managers, integrated health staff, and community health workers.
Participate in case reviews, interdisciplinary meetings, program evaluations, data collection, health outcomes reporting, and clinical audits.
Review and interpret laboratory results and provide insights and recommendations to the clinical team.
Contribute to quality improvement initiatives and collect and analyze patient outcome data to support care enhancements and compliance.
Maintain accurate, timely, and complete documentation of assessments, care plans, interactions, recommendations, and follow-up in the electronic health record using approved templates.
Ensure compliance with HRSA guidelines, Arizona state regulations, The Joint Commission standards, and relevant organizational policies.
Provide leadership in collaboration and service coordination, including defining skill mix and delegating tasks among licensed and unlicensed staff.
Provide patients and families with individualized education and emotional support regarding care plans, treatment options, and community resources.
Build and maintain relationships with external healthcare organizations to identify resources that support patient care.
Obtain medical records, laboratory results, and diagnostic results as needed.
Participate in team meetings and community events as required.
Promote interdisciplinary communication and collaboration and comply with the organization’s written standards, Compliance Program, Code of Conduct, policies, and procedures.
Travel to health centers as needed.
Perform other duties as requested or assigned.