Primary Care Ambulatory Registered Nurse - Montage Medical Group

Key Dimensions

This position includes care coordination, patient safety, quality outcomes, teamwork, patient education, and population health management.

Essential Duties And Responsibilities

• Primary Care Population Management & Care Coordination
• Serves 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 plans.
• Maintains ongoing assessment of patients' clinical status, including symptoms, medication adherence, and response to treatment plans.
• Identifies patients at increased risk for clinical deterioration and escalates care appropriately.
• Coordinates care across the outpatient continuum, including specialists, and ancillary services.
• Patient Assessment, Education & Engagement
• Performs independent nursing assessments using strong clinical judgment and critical thinking skills.
• Provides comprehensive patient and family education, including disease processes and treatment plans, medication regimens, preventative health and lifestyle modifications.
• Delivers education during end-of-visit consultations, nurse visits, and telephonic outreach.
• Engages patients in self-management and shared decision-making, promoting adherence and improved outcomes.
• Clinical Operations & Symptom Management
• Manages and triages incoming patient communication, including symptom calls and clinical advice requests, ensuring appropriate level of care and timely access.
• Utilizes 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 manner.
• Conducts independent nurse visits as appropriate, including education, follow-up assessments, wound checks, and care plan reinforcement.
• Conducts 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 & Safety
• Supports medication management in collaboration with providers, including refills, titration support, and adherence monitoring.
• Performs medication reconciliation to reduce risk of adverse events.
• Documentation, Communication & Compliance
• Documents all patient assessments, interventions, and outcomes accurately in the electronic medical record.
• Communicates effectively with providers and interdisciplinary team members to ensure continuity and safety of care.
• Maintains patient confidentiality in accordance with HIPAA regulations.
• Supports quality initiatives aimed at improving health outcomes, reducing unnecessary emergency department visits, inpatient admissions, and enhancing patient experience.

Education

• Associate’s Degree – Nursing

Montage Values

Employees 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.

Experience

• A 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.

Requirements

• California licensed Registered Nurse.

Skills & Abilities

• Strong interpersonal and communication skills.
• Patient-centric problem-solving skills.
• Critical thinking skills.
• Epic clinical documentation.
• Ability to effectively collaborate across a multidisciplinary care team.