Serving patients aged 18 and above, primarily from Multnomah, Clackamas, and Washington counties with limited out-of-area exceptions.

Services Provided:

• In addition to adult Primary Care, our specialty & consult services include:
• Addiction Services (including Medication-Assisted Treatment) and Complex Pain Management
• Behavioral Health, Mental Health, and Wellness
• Bone Health
• Chronic Disease Management and Diabetes Care
• Geriatrics and Senior Care
• Gender-Affirming and LGBTQ+ Primary Care
• Hepatitis C Treatment
• HIV/AIDS Care and PrEP (HIV Pre-Exposure Prophylaxis)
• Long Covid
• Procedure Clinic (including Joint Injections)
• Women’s Health Care

Department Key Responsibilities:

Supports complex, high-risk patients in the outpatient setting through advanced care coordination a

• Leading multimodal triage and proactive care coordination, utilizing telephone, electronic messaging, and in-person communication to facilitate timely clinical interventions and reduce avoidable acute care utilization.
• Embedding clinical nursing expertise within ambulatory workflows, supporting real-time decision-making and seamless care transitions across settings.
• Serving as a central point of contact for patients, families, and interdisciplinary team members to promote continuity of care and address emerging clinical concerns in a timely, efficient manner.
• Designing, implementing, and refining ambulatory care models that support safe, scalable, and sustainable nursing practice in alignment with clinic operations and patient population needs.
• Driving improvements in patient outcomes by integrating nursing judgment with patient education, system navigation, and advocacy in a complex outpatient care environment.

• Nursing professional certification in Ambulatory Nursing or other relevant specialty-population (e.g. Diabetes, Geriatrics)
• Current clinical nurse experience in an ambulatory care setting, including telephone triage. 
• Experience working in a Primary Care setting within the last three (3) years.