Chronic and Transition of Care Registered Nurse - Roosevelt Clinic

Adelante Healthcare; Phoenix (AZ); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical/Dental/Vision

PTO 3 weeks

10 holidays

403b retirement

Tuition reimbursement

Disability insurance

Job summary

Adelante Healthcare seeks an experienced Registered Nurse to join our Roosevelt clinic team, with duties including triage calls, patient assessments, and coordination of care with external specialists. This role covers Gila Bend and Wickenburg clinics as needed.

You will ensure accurate documentation, perform medication reconciliation, and support transitions of care, while delivering compassionate patient education and maintaining high standards of clinical care.

Qualifications

• Graduation from an accredited nursing program.
• Licensed with the AZ State Board of Nursing in good standing.
• CPR certification (AHA/Red Cross).
• 2–5 years of clinical experience.

Responsibilities

• Perform triage calls using clinical decision support tools.
• Participate in team meetings and quality initiatives.
• Provide patient education and care coordination.
• Coordinate referrals and seamless information flow with external providers.
• Conduct medication reconciliation and prepare for exams.

Skills

Triage skills

Clinical documentation

Patient education

CPR certified

Office software

Education

Registered Nurse (RN) license in AZ

Tools

Patient Management System

Microsoft Office

Job description

This position is based at our Roosevelt clinic but will cover Gila Bend and Wickenburg clinics as needed.

Who Are We?

At Adelante Healthcare, we believe that healthy people create healthy communities. Our mission is to improve the health of our communities by providing the highest level of primary and preventive care, making it affordable for everyone. For over 40 years, we have been dedicated to serving our communities by providing healthcare to those most vulnerable by offering health care services at nine locations throughout Maricopa County. By joining the Adelante Healthcare team, you become part of a patient centered caring organization that is playing a vital role in helping our communities.

Our Amazing Benefits

• Medical, Dental, and Vision available DAY ONE!
• 3 weeks Paid Time Off annually
• 10 paid Holidays annually
• 403b Retirement Account Savings Plan
• Tuition Reimbursement for eligible programs
• Employer-paid Short Term and Long Term Disability
• And MORE

What You'll Need To Have

• Graduation from an accredited nursing program.
• Licensed with the AZ State Board of nursing; license in good standing.
• Demonstrated understanding of clinical methods and techniques used in record-keeping systems.
• Demonstrated ability in implementing the principles and practices of supervision.
• Advanced computer efficiency in Microsoft Office suite (Word, Excel, PowerPoint, Outlook) and experience in Patient Management System.
• Meet the organization immunization requirement.
• Valid Arizona drivers license.
• 2-5 years of experience in a clinical setting.
• Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and Red Cross (cognitive and skills evaluations).
• Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations.

What You'll Be Doing Day to Day

• Performs triage calls using approved clinical decision support tools for the adult primary care, OB, and Peds populations.
• Participates in team meetings, designated Specialty Team meetings, and quality and process improvement initiatives.
• Helps facilitate health and disease patient education (including adults, peds, and OB populations) sessions.
• Coordinates continuity of patient care with external healthcare organizations and facilities such as referrals to outside specialties and ongoing two-way communication between providers and care teams.
• Develops relationships with external healthcare organizations and facilities in efforts to find additional resources.
• Coordinates outreach efforts to high-risk patients and hospital discharge and admissions. Will collaborate with health plans, hospitals, and skilled nursing facilities for transitional needs.
• Conducts comprehensive, preventative screening for patients and/or assists all support staff in daily patient interactions as needed.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient care based upon approved standing orders and protocols.
• Works collaboratively with the clinical team on data collection, health outcomes reporting, clinical audits, and programmatic evaluation.
• Review and take action on care team tasks and inbox messages.
• Review and interpret lab results.
• Identify barriers to care and social determinants of health.
• Prepare for and assist with patient exams in the clinic setting.
• Medication Reconciliation.
• Medication Refills.
• Prior Authorizations.
• Referrals.
• DME.
• Short Term Disability Support.
• Completion of Nurse Visits including but not limited to POCT items (flu, strep, UA, HCG testing).
• Helps evaluate clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Manages insulin titration for the diabetic population, which can include outbound calls to follow up.
• Excellent customer service and communication skills.
• Performs assessment and delivers patient-specific education plan.

Benefits

• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance