Nurse Transitional Care Coordinator - Improve Outcomes

Arizona Community Physicians; Tucson, Northern (AZ, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Arizona Community Physicians is seeking a Nurse Transitional Care Coordinator to lead patient outreach during transitions from hospital to home. You will assess medical status, identify needs, and document in the EHR while coordinating with PCPs and the ACO framework.

The role emphasizes medication reconciliation, patient education on conditions and discharge plans, and advocating for patients to improve outcomes while maintaining privacy and professional standards.

Qualifications

• Education: Completion of an accredited RN program.
• Current Arizona RN license.
• Minimum of one year of experience in case management involving chronic disease management and utilization management.
• Excellent written and verbal communication skills.
• Proficient with MS Word, Excel and Outlook.
• Computer proficiency and ability to quickly learn new applications.
• Communication and people-relationship skills to work with a diverse range of people.
• Skills in organization, prioritization, and multi-tasking.
• Professional demeanor and privacy considerations for patients and families.
• Must be able to act calmly and effectively in a stressful situation.
• Must be able to establish and maintain effective working relationships with medical staff and peers.
• Preferred Experience/Qualifications: Population health management, utilization management and quality programs. CCM credential is desirable.

Responsibilities

• Conducts comprehensive patient/caregiver outreach as part of transitional care management program in collaboration with patient’s PCP.
• Performs thorough patient assessment and clear and concise documentation in the EHR.
• Communicates with patients/caregivers in a respectful and dignified manner.
• Completes accurate medication reconciliation.
• Identifies needs or barriers to care and compliance.
• Educates patients on acute and chronic medical conditions.
• Educates patients on reasons for hospitalization, ED visit, and reviews discharge summary from discharging facility.
• Serves as the patient’s advocate.
• Accountable for timely patient outreach and EHR documentation.

Skills

Case management

Communication

Organization

Multitasking

Computer literacy

Education

Completion of an accredited RN program

Current Arizona RN license

Tools

MS Word

Excel

Outlook

Job description

Arizona Community Physicians is seeking a Nurse Transitional Care Coordinator to lead patient outreach during transitions from hospital to home. You will assess medical status, identify needs, and document in the EHR while coordinating with PCPs and the ACO framework.

The role emphasizes medication reconciliation, patient education on conditions and discharge plans, and advocating for patients to improve outcomes while maintaining privacy and professional standards.