**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 Pennsylvania RN or LPN license + 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** Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, veteran status, or any other status protected by federal, state, or local 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