Registered Nurse Bilingual/Spanish - Transition of Care

To ensure hospitalized VCC patients experience a smooth transition from hospital to home without any gap in care or services. Provide support to patients within the guidelines of the Nurse Practice Act. Assist with clinical and compliance audits, and peer review. Participate with the EHR team in identifying changes or enhancements necessary for the EHR system and make recommendations for change. Must be bilingual Spanish.

• Within the full scope of the Nurse Practice Act, assess, plan, organize, and provide nursing care to assigned patients in accordance with clinician’s instructions; make preliminary observations of, and prepare patients for medical treatment
• Perform triage of patients via telephone or in person to ensure patient has necessary resources
• Assess SDOH, assist in the elimination of barriers to care
• Request hospital documents related to patients’ acute care services
• Document treatment of patients and record and report significant changes in condition and general progress of patient as needed
• Serve as point of contact for local hospital discharge planners, receive hand-off information
• Contact local hospitals to obtain data on a daily basis
• Develop and maintain professional relationships with customers
• Provide patients with post-discharge education and resources as needed
• Serve as point of contact for patient and family as needed
• Work to eliminate adverse events caused by gaps in transition of care
• Counsel and advise patients, families and significant others regarding special medical problems and/or proper health care methods; prepare and maintain concise and complete records and reports
  

• Current California RN license and good standing with the Board of Registered Nurses
• Current CPR certification which includes in person certification and test on resuscitation models
• Bilingual English/Spanish
• Minimum three years’ experience in acute care nursing and/or outpatient clinic or medical office
• Experience in triage (in-person and via telephone)

• Demonstrated critical thinking, organizational and leadership skills; appropriate role modeling
• Strong history-taking skill; ability to make quick and accurate assessments and accurately complete documentation
• Ability to relate and communicate well with patients over the telephone, to physicians and to staff.
• Ability to maintain a high level of precision in judgment, accuracy of assessment and skill in problem solving under stress based on skill level and licensure and scope of practice.
• Experience/familiarity with computers, Microsoft Office products (Word/Excel), business e-mail communication systems and internet search capabilities

Preferred Skills/Knowledge/Abilities

• Experience/familiarity with Electronic Practice Management and Medical Records systems, NextGen preferred