Primary Care Liaison RN - CommonSpirit Health

Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California.  Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona, and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians, and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience, through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled -- qualities that are vital to maintaining excellence in care and service.  

Within Dignity Health Medical Foundation, Primary Care Centers utilize the RN team-based model of care. As such, the Primary Care RN is an integral part of the Dignity Health care team and performs patient care services that support the team-based care model. The Primary Care RN in this setting is expected to know his/her scope as defined by the California Business and Professional code and function at the top of his/her licensure.

The Primary Care RN works in collaboration with physicians, staff, clinic management and other healthcare professionals. This position works within the context of a primary care medical home, from a team approach and in continuous partnership with physicians and patients to promote timely access to needed care and the enhancement of patient and family well-being.

The Primary Care RN will use protocol-driven standing orders to perform comprehensive support to physicians consistent with their scope of practice performing at the top of their licensure. This may include evaluating lab data, providing instruction and education to patients, phone triage, and medication modifications.

The Primary Care RN will support the PCMH concepts by providing coordination of care which may include facilitating diagnostic and laboratory testing, ensuring timely scheduling of follow-up appointments with providers, and providing disease management education. He/she will be instrumental in the continuing development and process improvement of clinical point of care.

The Primary Care RN will provide leadership and guidance to LVN's, MA's to ensure they are practicing at the top of their licensure/capacity within scope of practice.

The Primary Care RN coordinates appropriate resources to facilitate and ensure the patient's progress through the continuum of care. This position provides patient education, disease management and population health services, and support to the physicians as they manage their patients with chronic diseases. This position is responsible for coordinating a wide range of patient self-management support and disease registry activities. To improve the effectiveness of health care for our population, the Primary Care RN will work with the extended care team to ensure the patient experiences a smooth transition across the continuum of care. Collaborates with the Ambulatory Care management program (Dignity Health Medical Foundation Managed Care Department) to refer patients who require intensive care management service and ensures smooth transitions between the clinic care team and the complex care team.

Minimum Qualifications:

• Three (3) years of experience as an RN
• A minimum of one year in the last five (5) years as an RN in an ambulatory community (including outpatient community health clinics, private physician offices, home health and hospices, public health settings, free-standing urgent care clinics) or primary care setting
• Graduate from an accredited school of nursing required
• Understanding of the concept of patient centered care and knowledge of team based care and evidence based clinical practice guidelines
• Proven ability to educate patients on self-management techniques and chronic disease/population health management
• Demonstrated ability to independently assess evaluate and interpret clinical information and care planning
• Ability to perform job functions independently and with minimal supervision
• Strong clinical assessment and critical thinking skills
• Ability to demonstrate leadership skills to delegate and provide direction/guidance to multidisciplinary team
• Effective oral written and listening communication skills necessary for constant interaction with patients families physicians and other members of the health team
• Able to stay organized and flexible in a work environment with multiple assignments and changing priorities
• Word processing keyboarding and non-scripted documentation skills
• Able to operate PC-based software program
• Excellent interpersonal organizational and customer service skills are essential
• Medical terminology and clinical reference tools
• Current RN License
• BLS Certification through the American Heart Association

Preferred Qualifications:

• Five (5) years of clinical patient care experience as an RN in a patient centered primary care setting.
• Experience in care coordination and chronic disease management preferred
• Bachelor of Science in Nursing or other advanced clinical degree preferred
• Training in motivational interviewing preferred
• Understanding of rapid cycle process improvement activities
• Knowledge of community resources preferred

Keywords: outpatient ambulatory clinic medical foundation medical group medical office medical practice public health home health urgent care