Position Summary   Job Description The Registered Nurse (RN) works collaboratively with all members of the care team to provide world class service to both the patients and staff of Martin’s Point. The RN coordinates the delivery of specialty services to assure the highest quality of care while efficiently utilizing available services and resources. This position provides excellent customer service in a timely manner resulting in improved patient care, satisfaction, and provider efficiency (availability/appt. access). The RN performs independent assessments (within scope of practice), provides patient education and demonstrates initiative and creative problem solving to address patient concerns. In addition, this position will take high level clinical direction from the RN Lead and Clinical Quality Specialist. This role requires flexibility, creativity and excellent communication between many disciplines to ensure continuity of patient care. Key Results Areas: Coordinates with internal providers and external specialty providers and/or hospitals to maintain continuity of patient care (e.g., post op care or invasive cardiac care) Prioritizes and schedule specialty/primary services to meet patient needs while maximizing available resources. Performs independent patient assessment to determine the level and urgency of specialty/primary care services, including pain assessment applying standard protocols for disposition. Maintains an adequate inventory of instruments and equipment that meet quality and infection control standards. Provides education regarding specialty diagnosis, procedures, medications, risk factor modifications, exercise prescription and follow up activities/care to patients and/or family members by phone or face to face. Coordinates with the team the patients identified with gaps in care and strategize on appropriate action to facilitate closure. Partners Providers and Population Health Nurses to support and improve quality outcomes and address gaps in care Reviews upcoming scheduled appointments to identify chronic disease patients. Analyzes the patient record for gaps in care and takes appropriate action to facilitate closure of these gaps. Participates in daily huddles and regular team meetings to improve workflows and contribute to improving patient population outcomes. Will receive day-to-day clinical direction from on-site RN Clinical Leads Performs other duties as requested/required. Possible specialties include but are not limited to: Cardiac Specialty Provides the following types of continuous nursing assessment during outpatient tests: Maintains intravenous therapy while administering dobutamine and contrast agents Monitors patient vitals and pain levels in response to testing Ensures patient safety by: Preparing patient and equipment (including maintenance of the Advance Cardiac Life Support Cart) for stress testing Providing interventions specific to patient response to testing. Perform/coordinate holter and event monitoring and data collection, including interpreting cardiac rhythms and educating patients on meaning of rhythms. Coordinate cardiac sonographer activities. Surgery Specialty Provides the interface to coordinate and maintain surgical schedules at various hospitals to ensure continuity of patient care. Develops and maintains pre-op education and patient instructions for all surgical procedures Maintains a sterile environment. Coordinates surgical pre-op testing. Foreign Travel Specialty Determines appropriate immunizations using CDC and provider protocols. Develops and deliver patient specific health counseling/education appropriate to patient travel destinations and patient health risks/history. Administers vaccines and follow up care according to protocols and patient health risk/history. Care Coordination/Desktop Management Triages telephone calls applying standard protocols for disposition, i.e. schedule an appointment, refer to emergency room, or offer home advice (knowledge base/scope of practice to support the various types of patient population and services: OB/GYN, Pediatrics, Family Practice, Internal Medicine, Surgical, Cardiac) Communicates with patient via telephone or portal and assess patient need using standard protocols in order to coordinate appropriate care and next steps Contributes to the health maintenance, wellness promotion, and disease management of our patient population and the community at large through aiding the providers in the collection and review of patient-level data and assuming leadership roles in flu clinics and similar clinic and community wellness initiatives. Performs processing of documents (prescription refills, specialist/facility reports, lab results, telephone notes per protocol/guidelines) as advised by the provider. Develops, implement and follow up on nursing plan of care with reference to patient’s age, gender, culture, community and family resources, barriers, and readiness for adherence. Conducts nursing care visits for the provisions of services such as allergy injections, chronic disease visits, coagulation therapy adherence, HIV risk reduction counseling, wound care, blood pressure monitoring, medication adherence counseling, and other procedures and interventions as appropriate. Skills/Knowledge/Competencies (Behaviors): Able to research and identify creative and effective solutions to patient, resource or coordination issues. Proactively seeks clarification and solutions to process issues Maintains complete and accurate documentation Able to develop policy and procedures Able to develop policies and training on equipment Acts as a Specialty resource to others Education/Experience: RN required (BSN preferred) 2+ years experience; at least one year as nurse responsible for independent decisions (such as triage nurse, home health nurse, clinical specialist or other subspecialty) BLS required; ACLS required for Cardiac Nurse We are an equal opportunity/affirmative action employer.