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The RN CareCoordinator collaborates to provide education and support for socialdeterminants of health and assists with managing high risk patients byassessing needs, developing, and implementing care-plans, and coordinatingservices. This RN also supports patientswith a variety of mental health diagnoses in finding mental healthresources. The RN Coordinator maintainsthe adequacy of the care-plan, advocates for the patient and family throughoutthe healthcare realm, and proactively works within the healthcare team to keepthe patient as healthy as possible. TheRN innovates and assists in the development of new programs, such aseducational programs for chronic conditions, and develops initiatives to reduceED utilization and Hospital Readmission. The RN works independently and as part of the Care Coordination teamwith the primary care providers and their patients at the Corvallis ClinicAsbury Building.
1. Will participate and maintain a culture withinThe Corvallis Clinic that is consistent with the content outlined in theService and Behavioral Standards document. To this end, employee will be expected to read, have familiarity, andembrace the principles contained within.
2. Works within the interdisciplinary team as partof our Patient Centered Primary Care Medical Home and collaborate with existingteam of RN Care Coordinators.
3. Provides nursing care according to thesequential steps of the nursing process: assessment, planning, intervention, implementation,and evaluation.
4. Develops and implements new programs as needed.
5. Assists with development and communication ofclinical changes defined by Primary Care First and other Quality contracts.
6. Reviewsinpatient utilization and discharge planning daily. Review notes faxed from hospital or SNF,assess patients, and communicate issues to healthcare team.
7. Provides or arranges for early intervention toavoid hospitalization of high-risk patients and arrange for community supportservices and equipment. Interface withthe providers, family, patients, and/or caregivers as appropriate.
8. Provides or arranges for follow up mental healthcare and navigation of resources.
9. Provides or arranges for follow up care withHome Health Services, Skilled Nursing Facility (SNF) services and subsequentdischarge planning. Conducts ongoingconcurrent review by reviewing SNF Rehabilitation meeting notes and frequentphone contact.
10. Coordinatescare for patients starting on hospice or palliative care.
11. Contactspatients after discharge from hospital or other inpatient facility to ensuredischarge needs have been met, assess for readiness to be home, reconcilemedications, and to coordinate follow up with primary care and otherspecialties. Contact patients within 2 days of discharge.
12. Reviews emergency department utilization anddischarge planning daily. Reviews notes fromhospital and communicates issues to healthcare team. Educate patients aboutalternatives to the emergency department. Contact patients within 7 days of EDvisit.
13. Participates in initiative to reduce EDutilization and assists in tracking these patients.
14. Makesappropriate referrals to health plans and ensure the coordination of patientservices and accuracy of reported data.
15. Works withindividual providers to facilitate changes in practice patterns, whenappropriate as directed by the Clinical Director or Manager.
16. Meets weeklywith select primary care teams to review hospitalization and ED use, carecoordination for high-risk patients, quality data, and to educate about newinitiatives.
17. Improvesthe quality of care through continuing education and self-evaluation of theeffectiveness of care. This includesattendance/participation in most in-services/department meetings and remainingcurrent on clinic/department policies and procedures.
18. Participatesin orientation and training of new employees.
19. Works withpatients individually and in the group setting.
20. Collaborateswith primary care providers by attending patient appointments, receiving “warmhand-offs,” and attending weekly primary care huddles.
21. Completesindividual patient Care Plans for home clinic to meet requirements of MedicalHome.
1. Graduate of an accredited school of registerednursing and one (1) year of nursing experience required.
2. Current unencumbered State of Oregon license asa Registered Nurse required.
3. Case Management certified or willingness toobtain within 2 years of employment required.
4. Current Basic Life Support (BLS) certificationor ability to complete BLS certification within 90 days of hire required.
1. Evidenceof working knowledge of the nursing process
2. Adaptability/flexibility& time management
3. Customerservice and the ability to work well both independently and as a member of amultidisciplinary team
4. Abilityto work on multiple tasks simultaneously in a busy, fast-paced environmentwhile maintaining quality of work
5. Knowledgeof chronic health conditions and their greater impact
6. Self-starter,motivated, and accountable
7. Abilityto communicate effectively in both written and verbal formats
8. Abilityto identify complex problems, review information, and navigate to reasonablesolutions
Full Time
$75k-94k (estimate)
02/04/2024
07/07/2024