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. Job Summary:    The Population Health Registered Nurse is 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 of utilization management systems for care transitions.    ESSENTIAL JOB FUNCTIONS 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 calls, text messaging, emails). Perform additional clinic and non-triage nurse duties such as instructing patients in general and specific medical care and health issues, providing skilled nursing services and treatment, administering and/or dispensing medication and injections; performs nurse visits as required. Other duties may be assigned by Supervisor. Administrative:  * Maintain awareness of current nursing protocols; participate in the formulation and revision of protocols and practices; attend and participate in staff meetings and in-service education. * Assist in the coordination of day-to-day clinic activities; orient, train, and direct other clinic staff in specific clinic operations and procedures. * Maintain inventory and order supplies, medications, controlled drugs, and equipment. * Perform quality control activities, including maintaining monthly quality control check logs and updating calibration and quality control records for medical instruments and equipment. * Assist other assigned R.N.s in overseeing clinical programs such as tuberculosis and hepatitis B, and immunizations etc.      GENERAL AGENCY/AHS DUTIES Foster an environment that promotes trust and cooperation among clients and staff. Enforce clinic policies and procedures, including maintaining client confidentiality in accordance with HIPAA privacy regulations, to ensure AHS principles are upheld. Play an active role in planning organization-wide activities, including AHS general membership meetings, fundraisers, special clinic days, and other events. Participate in general membership meetings, fundraisers, and other public events, as required. Participate in outreach activities, agency advocacy, and serve on ad hoc committees, as requested. Attend AHS staff retreats and Board of Directors meetings, as required. Participate in agency-wide quality improvement initiatives and performance improvement teams to support excellence in the quality of services provided across the organization. KNOWLEDGE, SKILLS & ABILITIES Requires thorough knowledge of the methods, procedures, and objectives of modern nursing/medicine, including an understanding of medical terminology and developing nursing care treatment plans. Knowledge of principles, practices, and procedures used in the treatment and documentation of health problems across all age groups, including the elderly. Knowledge of environmental, sociological, and psychological problems related to medical care across all age groups, including the elderly. Knowledge of laws, rules, regulations, protocols, and requirements pertinent to the practice of nursing in a clinic setting. Committed to working in the Asian community, and in community health care. Familiarity with community health clinics preferred. Experience in patient education. Experience in counseling and interviewing techniques. Ability to exercise sound clinical judgment within the scope of authority and practice. Good communication (both written and verbal), and strong interpersonal skills with both professional staff and clients. Excellent computer skills and experience with database management preferred. Exemplifies excellent customer service with AHS clients and co-workers. Detail-oriented with excellent problem-solving skills. Evaluating findings and results, determining deviations from normal, and under the direction of a physician, prescribing appropriate measures. Preparing and maintaining organized, detailed, and accurate medical records. Collaborating with other members of the health care team on an ongoing basis. Establishing and maintaining effective working relationships with those contacted in the course of work. Demonstrated ability to work both independently and as part of a team. Able to build relationships with key stakeholders in collaborating hospitals, as well as our primary care teams. Ability to work effectively and calmly while prioritizing multiple work demands. Well organized. Able to use electronic systems to track and report on work. Demonstrated self-starter, able to work effectively to create new systems. In the case of language discordance, the ability to effectively communicate with patients using an interpreter MINIMUM QUALIFICATIONS Requires graduation from an accredited school of nursing and possession of a valid RN license in the State of California. Bilingual in English and an Asian language. PREFERRED QUALIFICATIONS Valid California Driver’s License, insurance, and ability to travel as required to perform duties. Two or more years of clinical experience in the areas of adult medicine, chronic care, and/or triage. CERTIFICATIONS, LICENSES, REGISTRATIONS Valid CA RN License BLS certificate CPR certification required HIPAA Training Certificate Benefits That Support You We're committed to supporting our team's well-being. Our comprehensive benefits package includes: Health & Wellness * 100% employer-paid medical, dental & vision coverage * Acupuncture & chiropractic coverage Time Off * 12 vacation days * 12 sick days * 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime) Financial & Retirement * 403(b) with 3% employer contribution + up to 2% match * Flexible Spending Account (FSA) & Dependent Care Assistance Additional Support * Commuter benefits * Long-Term Disability Insurance   Please note: We are not seeking support from staffing agencies at this time. Direct applicants only.