Registered Nurse – Population Health

Asian Health Services, founded in 1974, provides medical, dental, and behavioral health services to more than 50,000 patients. Our approach to well‑being focuses on “whole patient health” for all. We go beyond our clinic walls and invest in our community’s overall health. We know that income, housing, and environmental struggles lie at the heart of poor health. That’s why we also address food insecurity, youth leadership, and culturally competent care while working towards supporting safer streets and vibrant communities.

The Population Health Registered Nurseis focused on the coordination of care for patients in the transition between hospital and primary care.

The position’s primary responsibility is working closely with hospitals, health plans, and clinic-based care teams to coordinate patient transitions between levels of care to reduce unnecessary admissions and readmissions and to ensure appropriate follow-through between systems of care. This position will also work closely with QI staff in the development ofutilizationmanagement systems for care transitions.

• Effectively communicate with appropriate staff from the clinics, hospitals, health plans, service organizations, and other community agencies to enable the efficient and timely exchange of clinical information and patient care coordination between points of care.
• Perform nursing assessment and patient triage which includes prioritizing cases, providing medical advice, making complex referrals, providing test results, and problem‑solving complex cases by handling patient telephone inquiries and walk‑ins requesting care.
• Coordinate and facilitate patient care using the clinic EHR systemand other confidential portals to exchange information.
• Maintain access to the established lists of high‑risk clients through a health plan portal or another confidential site.
• Maintain a hospital roster for patients in acute facilities for all sites.
• Make appointments or referrals as needed for hospital follow‑up (psychosocial, behavioral, or medical).
• Order labs, treatments, and other client needs based on organizationally approved standing orders, or refer to site team members who can use/implement the standing orders.
• Assist with the completion of forms/paperwork necessary for adequate patient care in the transition between hospitalization and resumption of outpatient care.
• Conduct medication reconciliation. Compare transfer orders to previous hospital orders as well as the client’s list of home medications, bringing discrepancies to the attention of the patient’s PCP/care team.
• Communicate clearly with patients about care plans and ensure understanding by the patient and/or their family, caretakers(s), or surrogate decision‑makers.
• Ensure patients and PCPs are well prepared for the hospital to follow up visits.
• Document all communications in the medical record.
• Coordinate with the Chief Medical Officer, Quality Improvement team, and health plans to organize, track, and report data, maintain data integrity, and use data to improve patient care outcomes.
• Collaborate with the health plan utilization departments to identify high‑risk patients to proactively improve care and prevent waste.
• Track the health outcomes of the clients in an Excel spreadsheet, medical record, or another tool.
• Pull simple reports by disease, provider, and preventive health measures, etc. for review as appropriate.
• Develop and present reports on utilization and quality measures.
• Represent AHS in care transition workgroup meetings with outside agencies.
• Participate in relevant meetings, training, and collaborative activities.
• Support patients in a variety of settings, including in‑clinic, and in patient’s homes either in person or using virtual visits (e.g. over phone or video…