People's Community Clinic·Austin, Texas
The Registered Nurse coordinates comprehensive care for high-risk populations through assessments, proactive monitoring, and patient education. They are responsible for triaging patient needs, managing provider in-baskets, and collaborating with the care team to implement individualized care plans.
Overview The Registered Nurse is an integral part of the health care team, fulfilling the Clinic’s mission by promoting and facilitating excellent health care for patients in accordance with established nursing standards. This position works as a member of a care team to coordinate patient care and support patients and families in self-management, self-efficacy, and behavior change. Care team members are expected to assess and manage the health needs of the patient population and to communicate effectively with all patients, especially vulnerable populations.
Under the direction of the Nursing Manager, this individual’s primary responsibilities include: Collaborate with the provider to coordinate comprehensive patient care for high-risk populations. Conduct thorough nursing assessments, including physical, social, and emotional needs, to inform individualized care plans and interventions. Conduct regular, proactive, monthly check-ins with patients on care management (via phone/telehealth) to monitor health, set goals, and provide education. Educate patients and families on diagnoses, treatments, medications, procedures, and self-management strategies to promote understanding, including managing conditions and navigating complex medical systems as indicated by nurse assessment or provider direction. Conduct coordination with community service organizations and make and/or specialist appointments and schedule other tests, treatments, or procedures as needed Perform transition of care outreach, including post-hospital discharge assessments and follow-up to support safe transition to primary care. Triage patient needs via telephone, walk-ins, and MyChart advice requests using evidence-based standards and protocols. Manage the provider in-basket efficiently, including timely response to patient messages, MyChart advice requests, and care coordination tasks. Provide clinical advice to patients per plan of care (POC), provider orders, or established protocols, ensuring safe and evidence-based recommendations. Serve as an advocate for patients and families, providing guidance, support, and resources to empower informed decision-making. Enhance the patient experience by practicing the AIDET model. Collaborate with the care team to identify, prioritize, and address patient and family needs in the development and implementation of care plans. Ensure compliance with HIPAA, state board of nursing regulations, the Nurse Practice Act, and all operational and pharmacy requirements. Perform other clinical duties as assigned, within the scope of practice and validated competencies.
Education: Graduate of an accredited school of nursing (RN).
Candidates must be a graduate of an accredited school of nursing with an unrestricted Texas RN license and BLS certification. Two to three years of related nursing experience is required, with a preference for backgrounds in case management or primary care.
Market context
In Texas, nursing roles like this often draw steady demand in dialysis and other patient-care settings because employers need licensed LVN/LPN candidates who can start safely and learn specialized workflows. These positions can be competitive when they require a current license, preferred dialysis experience, and completion of a training program soon after hire. Review the AI-summarized requirements and benefits here to save time, then confirm you meet the license, color-recognition, and training expectations before applying.