Transition of Care Registered Nurse (Behavioral Health)

Job DetailsJob Location: Adelante Healthcare Center Support Office - Phoenix, AZ 85012POSITION SUMMARY
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.
 
EXPECTATIONS
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.
 

OUR CORE VALUES
Inclusion
Nurture
Service
Purposeful
Integrity
Resilient
Engaged
Qualifications 
ESSENTIAL SKILLS AND EXPERIENCE

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

POSITION RESPONSIBILITIES/ESSENTIAL

Patient Care Responsibilities

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 self-management, health literacy, and wellness strategies.
Perform medication reconciliation during transitions, identifying discrepancies and ensuring a complete review of medication lists.
Collaborate with healthcare providers to recommend appropriate pharmacological therapies based on clinical assessments and evidence-based practice.
Coordinate outreach efforts to high-risk patients and hospital discharge and admissions.
Educate patients about their medications, including indications, adherences, and potential side effects.
Review and act on care team tasks and inbox messages.
Identify barriers to care and social determinates of health.
Perform medication refills, prior authorizations, and referrals.
Facilitate patient care based upon approved standing orders and protocols.

Clinical Collaboration

Actively support the referral process in accordance with AHC policies and procedure and standing orders, ensuring timely and efficient patient transitions post hospital discharge.
Partner with patients to develop Self-Management Goals (SMGs) framed within the SMART criteria (Specific, Measurable, Attainable, Realistic, Time-bound). This approach fosters patient-centered care by empowering individuals to take an active role in their health management.
Utilize critical thi