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Westside Family Healthcare · 8 hours ago

Ambulatory Care Nurse - RN $5000 Signing Bonus

Wilmington, Delaware

Full-time

Onsite

Mid Level

Westside Family Healthcare is a nonprofit organization that provides high quality primary medical care without regard to ability to pay. The Ambulatory Care Nurse (RN) serves as an integral member of the patient care team, managing high and rising risk patients and facilitating patient-centered education and self-management skill development.

Health CareMedicalNon Profit

Responsibilities

Manage a caseload of patients identified as at risk for health deterioration, sentinel events and/or poor outcomes using the nursing process and established protocols/workflows. Ongoing evaluation of care coordination efforts by measuring interventions effectiveness and fostering a continuous improvement mentality. Partners with the patient and family, the primary care provider, and other team members to implement an interdisciplinary plan of care

Participates in daily huddles with the Clinical Operations team, and other team meetings/trainings as scheduled

Proactively and continuously reviews patient medical records to identify any care needs requiring intervention or follow up during patient interactions

Works with patients and families to ensure both medical and psychosocial needs are met in order to promote health and well-being and to identify any barriers that inhibit the patient from adhering to the prescribed plan of care

Educates patient/family about medical conditions (existing or newly diagnosed) to assist them in appropriate self-management

Proactively incorporates lifestyle improvement opportunities and preventative care into patient interactions, empowering patients to reach their individual health goals

Assesses and documents progress towards goals based on provider’s plan of care; utilizing clinical judgment, established protocols, review of patients’ self-monitory tools and trends in clinical data (i.e., HbA1c, LDL, BP)

Promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk

Provides ambulatory care support as a member of the care team, which may include, but is not limited to walk-in and/or telephone triage utilizing established protocols

Proactively advocates for patient care issues to ensure overall quality and adherence to provider’s plan of care; ensuring care is sensitive to each specific patient’s needs

Participates in quality improvement activities and initiatives. Other duties as assigned

Maintains compliance with all professional and organization requirements to meet position standards