Care Team Registered Nurse

Summary

The Care Team RN is a key member of the multidisciplinary care team, providing high-quality, patient-centered care to diverse and vulnerable populations. This role involves responding to medical provider orders and referrals, conducting phone and in-person triage and completing assessments, delivering education, and providing care within the nursing scope. The Care Team RN also supports transitions of care, engages in population health activities, coordinates with external providers, and contributes to improved patient outcomes through leadership and collaboration.

Qualifications

• Currently licensed as a Registered Nurse in Maryland and/or the District of Columbia (both licenses required within 180 days).
• Current BLS certification.
• Bachelor’s degree in nursing.
• Fluent in written and spoken English and Spanish.
• Minimum of 1 year of clinical nursing experience required, or equivalent experience and education.
• Familiarity with electronic health records (EHR) and population health tools.
• Strong clinical assessment and decision-making skills.
• Commitment to health equity and serving vulnerable populations.
• Demonstrated ability to lead and collaborate within interdisciplinary teams.

Preferred Experience

• Experience working with pediatric patients.
• Experience working with perinatal patients.
• Experience working with the Latino immigrant community.
• Experience working with other diverse populations including the LGBT+ community, individuals experiencing homelessness, and/or individuals with substance use disorders.
• Experience developing and/or leading clinical competency training.
• Experience working in healthcare setting infection prevention and control.
• Motivational interviewing.

Skills and Abilities

• Knowledge of practical implementation of nursing process and clinical decision making within the nursing scope of practice.
• Effective and professional communication, both verbally and in writing.
• Ability to multitask, prioritize, and solve problems using critical thinking and clinical knowledge in a fast-paced environment.
• Ability to work independently within the nursing scope of practice while maintaining knowledge of available resources and when to ask for help.
• Ability to work collaboratively within a multidisciplinary team.
• Knowledge of standard clinical and office equipment and technology.
• Ability to work with diverse populations within a patient-centered, trauma-informed care model.

Responsibilities

Clinical Care

• Conduct comprehensive patient assessments and develop individualized care plans in collaboration with medical providers and other care team members.
• Exercise independent clinical judgment in managing acute and chronic conditions within scope of practice.
• Provide chronic disease management including blood pressure checks, glucose monitoring, insulin titration, and health education.
• Conduct in-person and telephone triage of unscheduled patients to determine level of care needed, collaborating with medical providers to meet patient needs within the context and limitations of clinic schedules.
• Provide care within the model of the Patient Centered Medical Home and using the framework of the Social Drivers/Determinants of Health to provide holistic, whole-person care.
• Serve as a clinical resource and advocate for patients, ensuring culturally competent and equitable care.
• Manage transition of care for recently hospitalized patients, assessing patient’s understanding of discharge instructions and level of follow-up care needed.
• Proactively seek opportunities to provide preventive care within scope of nursing license (immunizations, health screening, referrals, etc.).
• Support patient self-management and behavior change using motivational interviewing and coaching.
• Run staff vaccine clinics and patient health fairs/vaccine clinics as needed.
• Other duties as assigned.

Leadership

• Assist clinical leadership in fostering a respectful and inclusive team culture that values diverse perspectives and shared decision-making.
• Support, coach, and mentor medical assistants in clinical practice.
• Assist nursing leadership in carrying out clinical training for medical assistants and other staff members.
• Support patients, providers, and care teams in achieving quality measure goals.
• Champion evidence-based practices and contribute to protocol development and implementation.
• Demonstrate dedication to ongoing learning and development of clinical knowledge and skills via participation in professional development and learning opportunities.