Care Transitions Nurse, RN

Tiburcio Vasquez Health Center - Hayward, CA

Job Title: Care Transitions Nurse, RN

Position: Care Transitions Nurse in a patient-centered care team

Job Type: Full Time

Pay: $86,174.40 - $94,928.00

Shift: Typically Monday through Friday, with periodic Saturday hours

Work Type: On-Site

Location

Address:

City: Hayward

State: CA

ZIP Code:

Job Responsibilities

Maintain accurate tracking list of TVHC hospitalized adults from all local hospitals.
Maintain access to the established list of high risk patients through health plan portal or other confidential site.
Communicate clearly with TVHC patients about care plans.
Ensure timely and appropriate hospital follow up and medical appointments.
Notify TVHC staff as appropriate when patients are admitted to local hospitals.
Review hospital discharge plan and notify primary care providers and/or Hospital Discharge Coordinator of important medical and social issues during hospitalization.
Coordinate with Hospital Discharge Coordinator and Care Transitions CHW to organize, track, and report data.
Represent TVHC in Care Transitions work group meetings with outside agencies.
Provide quarterly statistics report to Sutter staff for all Care Transitions programs.
Support TVHC staff located at Eden Hospital and aid staff in effective communication with hospital staff and patients.
Initiate referrals for TVHC patients who qualify for additional home health services after hospitalization to include TVHC and community programs.
Provide nursing services including administration of medication and injections to patients as directed by the healthcare provider.
Provide immunizations, referrals to other providers and community health resources, and health instruction to patients following examinations.
Perform encounter forms and complete electronic health record entries (EPIC) for appropriate nurse-visits.
Assist Healthcare Provider with in-clinic examination and procedures as appropriate.
Perform patient chart updates during pre-visit prep, including reconciliation of medication list.
Obtain medical report from outside healthcare providers, facilitating communication to healthcare provider.
Assess the learning needs of patients and develop and implement patients’ education as appropriate.
Act as a resource and contact person for patients.
Obtain patient history for unscheduled patients arriving to the clinic as needed.
Provide clinical support for patient calls as appropriate to scope.
Perform assessment data collection and document subjective and objective data.
Review basic health history information for patients.
Collaborate with Registered Nursing and Healthcare Provider to meet patient care needs.
Visit patients in their homes and other ambulatory settings as part of the Care Transitions program.
Attend general and medical staff meetings and participate in quality improvement projects.
Assist the Chief Medical Officer and/or Chief Operations Officer on matters relating to nursing practices.
Assist in the performance appraisals of personnel through documentation and input to the COO.
Perform all duties and services in full compliance with TVHC’s Service Excellent Standards.
Perform all duties necessary for successful EHR/EPM entries and maintenance of patient/client records.
Perform other related duties as may be assigned by Hospital Discharge Coordinator, COO, and/or CMO.

Required Skills

Core Skills

Excellent communication skills
Ability to effectively communicate with patient population and staff
Intermediate to advanced computing and phone skills
Working knowledge of 'Universal Precautions'
Ability to multi-task and work effectively in a high-stress environment
Ability to maintain confidentiality according to HIPAA standards
Cultural sensitivity and effectiveness working with diverse populations

Preferred Skills

Bilingual in English/Spanish or other languages
Experience in an outpatient clinic

Requirements

Experience: Minimum 1-year experience as RN, in an outpatient clinic preferred.

Education:

License & Certification:

Current, valid California Registered Nurse license
Valid Cardiopulmonary Resuscitation Card (CPR)

Schedule:

Willingness to work evenings and/or weekends
Ability to travel to designated locations as needed

COVID-19 Requirements: Not Specified

Benefits

Medical (100% paid co-payments, premiums, etc.)
Dental and vision (including dependent and domestic partner coverage)
Generous paid leave benefits including holidays
Flexible Spending Accounts
Retirement plans with an Employer match
Tuition reimbursement
Monthly treats
Pet insurance

Supplemental Pay

Not specified

Special Notes

Not specified

Facility Details

Name: Tiburcio Vasquez Health Center

Description: A non-profit community health center dedicated to promoting the health and well-being of the community by providing accessible, high-quality care.

Specialties: