Care Center Nurse Advisor - RN ambulatory setting

New Haven, CT
Mar 1, 2019


Job Description

Nurse Advisor \u2013 RN ambulatory Yale CARE Center (Coordination, Appointment, Referral & Engagement )

6 positions

Looking for dynamic, seasoned RNs with excellent clinical and communications skills to support a call center to coordinate complex patient referrals and coordination of services in the Yale CARE Center as our patients transition from inpatient units or the emergency departments.

Please include an up-to-date resume with your application

Current care specialties included:


To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.


The CARE Center Nurse Advisor supports and coordinates complex patient referrals and assists with successful and effective transitions of care from the hospital or emergency department setting. The CARE Center Nurse Advisor is an integral member of the Yale Medicine CARE Center team ensuring timely and appropriate referrals to designated specialty clinics. The CARE Center Nurse Advisor coordinates services within the multidisciplinary clinical system resulting in exceptional patient care and provider experience. The CARE Center Nurse Advisor collaborates with Yale Medicine CARE Center and YNHH leadership to meet the needs of patient access and continuity of care. The CARE Center Nurse Advisor assists Yale Medicine and YNHH leadership teams with review of operational metric trends, development of performance improvement action plans, program development, expansion, and successful achievement of programmatic goals.

  • 1. Supports and enhances the process of scheduling patient appointments and referrals and assumes clinical nursing responsibilities associated with the Yale CARE Center.
  • 1.1. Serves as a clinical leader, patient resource, and advocate for disease specific pod within the Yale Medicine CARE Center .
  • 1.2. Maintains excellent understanding of evidence-based medicine and disease entities of specified clinical program.
  • 1.3. Provides knowledge on specific diagnosis, specialties, and assists with interpretation and triage of specialty clinical algorithms.
  • 1.4. Ensures prioritization of patient's specialty appointments, including the appropriate specialty, provider, and timeframe based on incoming referral information. Follows up for clarity as needed.
  • 1.5. Participates with YM CARE Center leadership and specialty services for ongoing review of protocols and algorithms; provides updates as needed to facilitate high quality, safe access of patient appointments.
  • 1.6. Collaborates with the specialty teams to ensure process for follow up appointments are confirmed for patients post ED and/or inpatient discharge.
  • 1.7. Provides patient and families with education regarding their disease process, medications, treatment, and plan of care.
  • 1.8. Assumes responsibility for clinical calls received by the YM CARE Center utilizing emergent and urgent clinical triage guidelines within the nursing scope of practice. Refers patients to the Emergency Department as needed and/or for further triage to specialty services for decision making. Ensures follow through and communication of patient's plan of care.
  • 1.9. Utilizes the electronic medical record for appointment scheduling following established guidelines. Facilitates access to My Chart and related technologies to enhance electronic communications and patient experience.
  • 1.10. Documents all patient and family interactions in the electronic medical record according to established protocols.
  • 1.11. Functions as an educational resource for schedulers, patients, and families.
  • 1.12. Provides cross coverage for other specialty areas as needed.
  • 1.13. Attends and actively participates in staff meetings and trainings.
  • 1.14. Performs all other duties as requested.
  • 2. Serves as the clinical liaison between patients, families, referring providers, specialty teams, and community to ensure timely, efficient, and seamless access to appointments.
  • 2.1. Collaborates with specialty providers and specialty teams to address any identified gaps in, or barriers to care; intervenes as appropriate.
  • 2.2. Leads the coordination of complex patient referrals by collaborating with the scheduling staff to facilitate the patient's entry into the healthcare system, aligning right care, right provider at the right time for each patient.
  • 2.3. Supports providers and optimizes efficiencies including pending orders in preparation for scheduled office visits or medication refills.
  • 2.4. Assumes responsibility for clinical calls received at the Yale Medicine CARE Center; triages calls to disease specific clinic nurses as appropriate.
  • 2.5. Follows up with specialty clinics to address any identified gaps in referrals and intervenes as appropriate.
  • 2.6. Assists patients and families in addressing their needs and concerns to ensure understanding of clinic visit.
  • 2.7. Supports and enhances communication and coordination of clinic visit with patient/family, referring provider, and specialty team.
  • 2.8. Is a patient and provider advocate appropriately escalating issues to YNHH and YM CARE Center Leadership.
  • 2.9. Reviews disease specific needs for urgent requests and facilitates process/guidelines to ensure specialty accessibility, patient scheduling, and communication.
  • 2.10. Maintains responsibility for post discharge phone calls identifying issues or concerns related to patient satisfaction and follows up as appropriate. Develops and implements corrective action as appropriate
  • 2.11. Monitors daily reports to identify Yale Medicine patients discharged from the hospital or emergency department who may need follow-up with the specialty practice in order to avoid readmissions.
  • 2.12. Provides outreach to community physicians and community agencies; collaborates with physician liaisons to establish relationships and ensure ongoing dialogue regarding patient referrals and needs. Works collaboratively to remove any identified barriers.
  • 3. Assists YNHH and YM Clinical and Administrative leadership with monitoring of Key Performance Indicators (KPI) and engages in performance improvement activities related to transitions of care and patient access to care.
  • 3.1. Monitors KPI metrics.
  • 3.2. Collaborates with YNHH Quality and Safety team regarding chronic, complex population; Care Center Nurse Advisor to monitor inpatient and ED discharges, hospital admissions and readmissions.
  • 3.3. Participates in the development and execution of action plans with YNHH Service line and YM CARE Center Specialties to ensure key objectives and service line goals are achieved.
  • 3.4. Generates operational and quality reports as needed and provides ongoing feedback to YNHH and YM CARE Center; identifies and escalates trends to appropriate leadership.
  • 3.5. Supports and exhibits YNHH HRO initiative.
  • 4. Functions as a resource for patients requiring coordination of multiple appointments.
  • 4.1. Responsible for coordination of provider specialty visits, diagnostic testing, procedures, ancillary services, and sequencing of appointments to meet the needs of the patient/family.
  • 4.2. Participates in YNHH Service Line meetings to enhance the processes for accessing services for complex and chronic care.
  • 5. Supports activities related to transitions of care.
  • 5.1. Monitors daily reports to identify Yale Medicine patients discharged from the hospital or emergency department who may require follow up care in a YM specialty practice.
  • 5.2. Within disease specific pod, follows up with patients discharged from hospital to assess patients understanding of plan of care, medication management, and provides education as needed. Ensures collaboration with specialty team for ongoing needs.
  • 5.3. Contacts patients discharged from the ED to ensure patient understands and is compliant with ED discharge plan.
  • 5.4. Post hospital or ED discharge, works with specialty team to ensure efficient and timely transition of care to specialty clinic visit or community healthcare agencies.
  • 5.5. Ensures documentation of all patient and family interactions in the EMR according to established protocols.

    Other information:


    BSN or Associates degree in Nursing required. Masters degree in Nursing or Healthcare preferred


    Three (3) to five (5) years experience in acute or ambulatory care required. Experience in a combination of the following is essential: clinical care specific to the specialty pod, clinical process improvement, outcomes management, case management, and physician relations. Experience in collaborating with members of the care team to coordinate specialty complex needs is required. Excellent oral and written communication skills is essential. Knowledge and understanding of standards related to the Joint Commission certification process preferred.


    Current State of Connecticut RN license.


    Candidate must be able to thrive in a fast paced, complex academic medical environment where the CARE Center Nurse Advisor works as a valued member of the multidisciplinary team. Background in disease specific entity preferred. Must possess understanding of clinical processes, organizational dynamics, and process improvement . Must be self motivated, goal oriented, and able to work independently. Must have the ability to develop relationships and work collaboratively and effectively in partnership with patients, families, physicians, clinical staff, hospital departments, community, and outside organizations. Must have excellent assessment, communication, and organizational skills with the ability to manage and follow through on multiple priorities. Excellent critical thinking , analysis, and assessment skills for successful process improvement planning and monitoring. Proficient in computer and data management.

    Accountable for ensuring patient needs are met throughout the continuum of care. Assist disease specific program with addressing barriers to care, coordination of services and other psychosocial needs. Responsible for identifying gaps and/or trends in care and assists providers and administration with implementing practice changes that support evidence based practice.

    Must be able to accommodate complex, emotional, and challenging needs of specialty patients and families; remains empathetic and is able to advocate among the care team and providers.

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    Job Info

    Job: 6007

    Department: YM CARE Center Nursing
    Category: Nursing-staff
    Sub Category: AMB/CLINICS/COMMUN
    Status: Full Time
    Shift: DAY/EVENING
    Hours: 40.00

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