Transition of Care Registered Nurse

Job Location:

Adelante Healthcare West Phoenix - Phoenix, AZ, Salary Range:
Undisclosed

The Transition of Care (TOC) Registered Nurse is responsible for facilitating seamless transitions for patients between healthcare settings. This role involves comprehensive patient assessments, care coordination, patient education, and strict adherence to regulatory requirements from HRSA, Arizona state regulations, and The Joint Commission, ensuring high-quality care for our underserved population.

This position is essential to Adelante’s team-based primary care medical home model of care, which supports coordinated, patient-centered, comprehensive healthcare for all. This role will perform work primarily remote and occasional travel to health centers or company facilities may be required.

Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected to work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism, and competence.

• Inclusion
• Nurture
• Service
• Purposeful
• Integrity
• Resilient
• Engaged

• Graduation from an accredited nursing program
• Licensed with the AZ State Board of Nursing
• License to be in good standing
• Demonstrated application of Nursing Planning (Assessment, Nursing Diagnosis, Goals/Outcomes, Implementation, and Evaluation)
• Demonstrated understanding of clinical methods and techniques used in record-keeping systems
• Demonstrated ability in implementing the principles and practices of supervision
• Good working knowledge of Microsoft Office applications, including Outlook, Word, and Excel
• Must be able to write analytic reports integrating multiple data elements and perspectives
• Must be familiar with Adelante healthcare mission, vision, and core values and use them during patient care and collaboration with non-clinical and clinical teams
• Must be able to maintain confidentiality, privacy, and security of protected information
• Must possess excellent verbal and written communication skills, with the ability to communicate effectively with internal and external customers
• Travel to all health centers is required as needed
• Advanced computer efficiency in the Microsoft Office suite (Word, Excel, PowerPoint, Outlook) and experience in the Patient Management System
• Meet the organization's immunization requirement
• Valid Arizona driver’s license
• Two (2) to five (5) years of experience in a clinical setting
• Certification to perform cardiopulmonary Resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and the Red Cross (cognitive and skills evaluations)
• Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations
• Participation in Community Events as required

• Electronic Health Record experience;
  Next Gen experience a plus
• Bilingual (Spanish/English), preferred

• Conduct comprehensive initial and ongoing assessments of patients' medical and behavioral health needs during transitions from inpatient to outpatient care or between service providers.
• Support transition of care (TOC) through coordination of continuity of patient care with internal and external healthcare organizations and facilities, such as referrals to outside specialties and ongoing two-way communication between providers and care teams.
• Engage patients actively in their care processes, promoting…