Hospital, Public and Private, Independent Medical Groups, Medical Group, Office of Physicians
Position Description: The Bilingual Primary Care Team Nurse is responsible for the day to-day delivery of appropriate, timely and beneficial care coordination for patients, promoting quality healthcare and outcomes. Works in an inter-disciplinary care team environment, with multiple disciplines and administrative functions across the organization and in a highly populated Spanish-speaking community.
Develops, implements and evaluates care plans for each primary care patient in coordination with the primary care physician and other team members, such as PharmDs, social workers, and behavioral health resources.
Triages patient complaints using clinical knowledge to suggest appropriate level of care. Assesses patients by phone and in clinic. Collaborates with providers to provide high quality care.
Supports care coordination with community providers, including medical specialists, home health and DME providers.
Assists in patients’ transition of care from hospital to home. Supports discharge planning and proactively manages medication changes, home care needs, and scheduling post-discharge visits, etc.
Provides education and clinical information to patients regarding their disease process, self-care, and wellness, all toward the goal of improving health outcomes.
Uses reports and other analytical tools to assess the needs of the primary care panel overall – such as gaps in care, risk factors, and outcomes – to analyze trends and make adjustments in care.
All other duties as assigned.
Bachelor’s or Associate's Degree in Nursing. Current registered nurse license in state of Pennsylvania.
Bilingual – Fluency in English and Spanish (reading, writing and speaking).
One (1) year experience in an active clinical environment (including but not limited to: hospital, urgent care, primary care).
Basic Life Support (BLS) certification is required: ACLS, NRP, ATLS, ALSO and PALS as required for specialty.
Excellent interpersonal and communication skills required to effective handle team members, patients, and family members.
Ability to perform job using theory-based nursing practice model, evidenced based practices, and shared governance in a multidisciplinary team model.
Ability to demonstrate reliability and responsiveness to patients, families and team members.
Ability to demonstrate mutual respect and build a trusting environment with patients, families and team members.
Knowledge of scope of patient care services provided by other clinical service lines and the referral process.
Knowledge of general medical procedures and the ability to anticipate complications and the indicated therapeutic interventions.
Knowledge of clinic practices and ability to act as a resource for clinic personnel and assist the Providers as necessary.
Ability to receive information, concerns and feedback in a supportive manner.
Ability to assess external factors that impact health and behavior.
Internal Number: 002
About CityLife Neighborhood Clinics
CityLife Neighborhood Clinics… Improving health block by block… It’s a movement! CityLife is changing how patients should think of primary care. Like the old family doctor, primary care is the first place to go for all your health needs. A primary care physician has been the first stop to diagnose & treat illness. Now, primary care is still where you go when you are sick & want to feel better, but also when you need help with the health care system & when you are well & want to get healthier.
Only you can improve your health, but you do not have to do it alone. At CityLife, we know health is more than just physical, which is why we have a care team in place to take care of the whole you, as a person, and not as a condition! The minute you walk in the door, a warm family feel not only makes you feel cared for, but comfortable. At CityLife, you not only have a doctor, but a whole team of health care professionals built around you and your needs! The health care system is hard to navigate, and at CityLife, we know that. That is why we have made it our mission to make health easier by offering same-day visits, walk-in care and so much more!