**Employment Type:** Full time **Shift:** **Description:** The Ambulatory Nurse serves as the clinical liaison between patients and the medical team, providing comprehensive support in an outpatient primary care setting. This role requires the ability to work independently, solve problems, and multitask effectively. Responsibilities include transitional care management, care coordination, patient triage, medication adherence promotion, and oversight of clinical quality measures to ensure exceptional patient care and practice performance. **Key Responsibilities:** + Identify patients requiring preventive care, chronic disease management, laboratory tests, screenings, or referrals, and coordinate services to meet their needs. + Perform transitional care management, including reviewing hospital discharge information, conducting medication reconciliation within two days of discharge, and scheduling follow-up appointments. + Triage patient phone calls and respond to inquiries with clinical expertise, ensuring timely and accurate resolutions. + Communicate test results to patients under provider supervision, offering appropriate guidance and next steps. + Support medication adherence through patient education and follow-up communication. + Accurately and efficiently document medical information in the electronic medical record system, maintaining compliance with documentation standards. + Lead efforts to close preventive care gaps and monitor clinical quality measures, ensuring the practice meets all associated metrics. + Promote best practices and contribute to the practice's success in achieving quality and operational goals. **Qualifications:** + Active RN or LPN license. + Bilingual English/Spanish (required). + Experience in primary care or ambulatory care is preferred. + Strong communication, organizational, and critical-thinking skills. **Skills and Attributes:** + Proficient in care coordination and transitional care management. + Demonstrated leadership in quality improvement initiatives and closing care gaps. + Ability to manage multiple tasks efficiently in a dynamic environment. **Our Commitment to Diversity and Inclusion** Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. EOE including disability/veteran