Primary Care Ambulatory Registered Nurse - Montage Medical Group

Welcome to Montage Health’s application process!Job Description:MMG Ryan Ranch Bldg. A - Primary CarePay Range: $65-$71The Primary Care Ambulatory RN serves as a clinical partner to MMG physicians and advanced practice providers, supporting patients across the spectrum of general primary care within the outpatient setting. This role emphasizes patient safety, continuity of care, telephone triage, and disease management.The Ambulatory RN comprehensively assesses patient health status to support the development, execution, and evaluation of individualized and population-based care plans. This role utilizes clinical judgment, data, and evidence-based guidelines to drive high-quality cardiovascular care. Key dimensions of this position include care coordination, patient safety, quality outcomes, teamwork, patient education, and population health management.Essential Duties And ResponsibilitiesPrimary Care Population Management & Care CoordinationServes as a primary RN resource for patients with acute and chronic conditions, including diabetes, hypertension, respiratory conditions, and routine primary care diagnosis.Collaborates with physicians and advanced practice providers to develop, implement, and evaluate evidence-based care plansMonitors patients’ clinical status, including symptoms, medication adherence, and response to treatment plansIdentifies patients at increased risk for clinical deterioration and escalates care appropriatelyCoordinates care across the outpatient continuum, including specialists, and ancillary servicesPatient Assessment, Education & EngagementPerforms independent nursing assessments using strong clinical judgment and critical thinking skillsProvides comprehensive patient and family education, including:Disease processes and treatment plansMedication regimens (e.g., antihypertensives, anticoagulants)Preventative health and lifestyle modificationsDelivers education during end-of-visit consultations, nurse visits, and telephonic outreachEngages patients in self-management and shared decision-making, promoting adherence and improved outcomesClinical Operations & Symptom ManagementManages and triages incoming patient communication, including symptom calls and clinical advice requests, ensuring appropriate level of care and timely accessUtilizes standardized workflows and protocols to support safe, efficient patient disposition (e.g., home care, same-day visits, emergency department, or escalation to provider)Recognizes abnormal findings and communicates changes in patient condition to providers in a timely mannerConducts independent nurse visits as appropriate, including education, follow-up assessments, wound checks, and care plan reinforcementConducts Primary Care Acute Care visits as appropriate, including IV fluid and medication administration (e.g., anti-emetics, NSAIDS, diuretics), patient education, and care coordination (e.g., diagnostic imaging, labs.).Medication Management & SafetySupports medication management in collaboration with providers, including refills, titration support, and adherence monitoringPerforms medication reconciliation to reduce risk of adverse eventsCare Coordination & Resource ConnectionConnects patients to supportive services, including:Care management / complex care programsSocial work and community resourcesHealth coaching and disease management programsAddresses barriers to care, including access to medications, transportation, and follow-up servicesDocumentation, Communication & ComplianceDocuments all patient assessments, interventions, and outcomes accurately in the electronic medical recordCommunicates effectively with providers and interdisciplinary team members to ensure continuity and safety of careMaintains patient confidentiality in accordance with HIPAA regulationsSupports quality initiatives aimed at improving health outcomes, reducing unnecessary emergency department visits, inpatient admissions, and enhancing patient experienceEDUCATIONAssociate’s Degree – NursingBLSMONTAGE VALUESEmployees of Montage Medical Group are expected to uphold the Montage Values and Service Standards. Montage Medical Group employees find joy in caring for those we service, are dedicated to coordinating care across all settings, take ownership, collaborate to deliver the highest quality care and are entrusted to serve our community with respect.ExperienceA minimum of 3 years of practice as an RN (acute care experience preferred). Experience with electronic medical record documentation. Working knowledge of quality standards and evidence-based practice.RequirementsCalifornia licensed Registered Nurse. Strong letters of recommendation (2).SKILLS AND ABILITIESStrong interpersonal and communication skillsPatient-centric problem-solving skillsCritical thinking skillsEpic clinical documentationAbility to effectively collaborate across a multidisciplinary care teamAssigned Work Hours:Position Type:MH - Non Physician