Complex Care Registered Nurse

Tri-Valley Career Center; Pleasanton (CA); On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Health, dental and vision benefits

403(b) retirement plan with employer 


Educational reimbursement

Job summary

Axis Community Health is seeking a Complex Care Registered Nurse (RN) to join its Enhanced Care Management (ECM) team in a Federally Qualified Health Center setting. The RN will provide clinical support, triage patients with high medical complexity, and collaborate with medical and behavioral health providers to deliver culturally competent care.

The role requires a BSN or equivalent, 2+ years of experience with high-need patients, and an active California RN license.

Qualifications

• BSN or equivalent required.
• 2+ years experience with high-need patients.
• California RN license required.
• Experience in primary/ambulatory care.
• CPR/First Aid and mandated programs.
• Ability to work independently and with a multidisciplinary team.

Responsibilities

• Manage a caseload of high-risk Medi-Cal members with ECM team.
• Assist patients with care coordination across internal and external sources.
• Provide RN coverage for nursing services as per Title 22 CC Section 75028.
• Document patient care in EHR and maintain HIPAA compliance.
• Provide triage, patient education, and follow-up per protocol.
• Collaborate with care teams to ensure continuous and quality patient care.

Skills

RN license

Clinical assessment

Communication skills

HIPAA compliance

Independence

Education

BSN or equivalent

Tools

EPIC EHR

Practice management systems

Job description

Company Description

Axis Community Health, a nonprofit established in 1972, provides comprehensive healthcare services to over 15,000 individuals across all age groups in the Tri-Valley area. The mission of Axis Community Health is to provide quality, affordable, accessible and compassionate health care services that promote the well‑being of all members of the community.

Our mission is rooted in delivering high‑quality patient care, encompassing primary healthcare, mental health support, and dental services. We are committed to ensuring access to essential healthcare services for every member of our community, irrespective of financial status, living situation, or insurance coverage.

Job Summary

The Complex Care Registered Nurse (RN) within the Enhanced Care Management (ECM) program at Axis Community Health plays a vital role in delivering compassionate, patient‑centered care in a Federally Qualified Health Center (FQHC) setting. The position will be working collaboratively with the ECM team, medical and behavioral health providers, and other care team members. The RN provides clinical support and triage to patients within the ECM program, including individuals with high medical complexity, chronic conditions, behavioral health needs, social determinants of health challenges, and frequent emergency room utilization. This position supports underserved and diverse populations and promotes health equity through culturally competent care. The RN upholds Axis's mission to serve the community with accessible, high‑quality health care for all.

Qualifications

• Graduate of an accredited nursing program with a Bachelor of Science in Nursing (BSN), or equivalent degree is required.
• Minimum of two (2) years' experience working with patients with high needs and chronic medical conditions, preferably in a hospital or clinic setting is required.
• Currently active California Registered Nurse (RN) license is required.
• Experience and knowledge of primary care medical services and ambulatory care.
• Ability to meet requirements of CPR, First Aid and other mandated programs.
• Demonstrate clinical assessment skills at the level necessary to provide clinical care independently, assess and provide triage where necessary.
• Ability to make independent decisions related to patient next steps and collaborate with multidisciplinary team.
• Knowledgeable of nursing and medical practices and procedures, as well as laws, regulations and guidelines that pertain to medical care.
• Effective interpersonal and communication skills, ability to effectively build rapport with patients. Build trust and outreach to patients who may be difficult to reach.
• Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, and policies and procedures that are necessary for providing quality care.
• Capable of researching new methods and principles to incorporate them into existing nursing practices.
• Ability to use the Axis practice management systems and the EPIC Electronic Health Record (EHR) system.
• Strong analytical, employee relations, and proven decision‑making skills.
• Excellent writing, business communication, editing, and proofreading skills.
• Ability to interact effectively and in a supportive manner with people of all backgrounds.
• Proactive, self‑motivated and able to work independently as well as on a team with the ability to exercise sound independent judgment.
• Ability to maintain a high level of confidentiality and a professional demeanor and must positively represent the organization at all times.
• Ability to establish and maintain positive and professional working relationships.
• Must be able to adjust priorities quickly as circumstances dictate.
• Must be able to be at work regularly and on time.
• Must be a dynamic self‑starter with demonstrated ability to work independently or in a group setting.
• A can‑do attitude, attention to detail, ability to set priorities.
• Ability to type a minimum of 35 WPM with minimal errors.
• Must have good computer skills using Microsoft Office and the ability to use Axis departmental systems.
• Must be able to use office equipment (i.e. copier, fax, etc.).

Essential Duties/Responsibilities

• Manage a caseload of high risk Medi‑cal members and collaborate closely with community health workers within the enhanced care management team.
• Assist patients with care coordination needs across internal integrated network and external referral sources.
• Provide RN coverage for nursing services as per the Title 22 CC Section 75028.
• Protects patients and employees by adhering to infection‑control policies and protocols, medication administration and storage procedures, and controlled substance regulations.
• Meetings with patients within the enhanced care management program in person at clinic location, or off‑site as warranted. Documents patient care in patient EHR record.
• Maintains continuity among team by documenting and communicating actions, irregularities, and continuing needs.
• Maintains patient confidence and protects operations by complying fully with HIPAA regulations.
• Maintains nursing supplies inventory by checking stock to determine inventory level, anticipating needed supplies, placing and expediting orders for supplies, verifying receipt of supplies, and using equipment and supplies as needed to accomplish job results.
• Maintains a cooperative relationship among health care teams by communicating information, responding to requests, building rapport and participating in team problem‑solving methods.
• Ensure that services are provided in a manner that is appropriate to patient needs and in full compliance with established medical protocols and legal and programmatic requirements.
• Provide direct patient care, to include the administration of medications and immunizations, performing nursing procedures, wound care, medical supply co‑order with physician, triage, and patient education regarding medical symptoms, diagnoses or medication as within scope.
• Provide triage services, to include patient assessment, referrals, and appropriate follow‑up.
• Provide back‑up assistance for other duties as assigned.
• Participate in staff meetings such as ECM, RN and other meetings and training events as assigned.
• May be required to perform other related duties, responsibilities, and special projects as assigned.

Benefits

• Employer paid health, dental, and vision benefits to the employee.
• Option to participate in a 403(B) retirement plan with employer matching contribution.
• Partial educational reimbursement.
• 12 paid holidays.
• Accrued paid time off with each pay period.
• Employee discount programs.

Connect With Axis

Company Page: https://www.axishealth.org

Facebook: https://www.facebook.com/axiscommunityhealth

LinkedIn: https://www.linkedin.com/company/axis-community-health

Annual Gratitude Report: https://issuu.com/axiscommunityhealth/docs/gratitudereport2024

Physical, Cognitive, And Environmental Working Conditions

Work is normally performed in a typical clinic office work environment (and, in some cases, telecommuting sites). The physical demands described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations can be made to enable individuals with disabilities to perform the essential functions of this position if the accommodation request does not cause an undue hardship.

Physical: Occasionally required to carry/lift/push/pull/move up to 20lbs. Frequently required to perform moderately difficult manipulative tasks such as typing, writing, reaching over the shoulder, reaching over the head, reaching outward, sitting, walking on various surfaces, standing, and bending. Occasional travel to other Axis health centers and other occasional travel will be required.

Equipment: Frequently required to use repetitive motion of hands and feet to operate a computer keyboard, telephone, copier, and other office equipment for extended periods.

Sensory: Frequently required to read documents, written reports, and signage. Must be able to distinguish normal sounds with some background noise, as in answering the phone, interacting with staff etc. Must be able to speak clearly, understand normal communication, and be understood.

Cognitive: Must be able to analyze the information being received, count accurately, concentrate and focus on the given task, summarize the information being received, accurately interpret written data, synthesize information from multiple sources, write summaries as needed, interpret written or verbal instructions, and recognize social or professional behavioral cues.

Environmental Conditions: Frequent exposure to varied office (medical clinic/office) environments. Rare exposure to dust and loud noises.

Disclaimer: This job post is not necessarily an exhaustive list of all essential responsibilities, skills, tasks, or requirements associated with this position. While this is intended to be an accurate reflection of the position posted, Axis Community Health reserves the right to modify or change the requirements of the job based on business necessity.

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