The Opportunity

The High Risk Programs is seeking an experienced full-time Registered Nurse with Care Management or Case Management backgrounds to join the new Transitions of Care team. This is a fully virtual role supporting patients in multiple states/markets (MA, GA and NC). The Transitions of Care RN will support the care of One Medical Senior Health patients discharged from ER visits/stays, acute, and post-acute stays, creating appropriate care plans, and working with internal and external care team members to coordinate care.

The ideal candidate is goal oriented, uses critical thinking and creativity to address challenges, and is comfortable with ambiguity. You are skilled in chronic disease education and care management, and passionate about Seniors' health and demonstrate outstanding clinical aptitude and judgment when caring for a patient.

What you'll likely work on:

• Provide transitional case management to a revolving panel of Senior patients; working with patients, families, providers, and healthcare facilities to improve clinical outcomes and help reduce readmissions to acute care settings.
• Interact with internal and external care team members to provide complex coordination for patients needing short-term case management and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments.
• Serve as the primary liaison between partner providers and the patient's primary care physician (PCP) team during time of transition, engaging in care planning, medication reconciliation, pre- and post-discharge planning, and facilitating safe handoffs of care.
• Manage assigned patients with the purpose of helping them be more effective at managing their own care, understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately.
• Create a patient centered-care plan with each patient and consistently document planned interventions and patient self-management strategies.
• Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health.
• Communicate significant clinical information regarding assigned patients to other members of the healthcare team and especially to the patient's PCP.
• Attend case conferences and team huddles as appropriate to support and facilitate patient care collaboration
• Effectively navigate health insurance policies and guidelines related to primary care, specialist, acute, rehabilitation and long term care.
• Develop a positive working relationship with sponsor care management staff.
• Build strong relationships with health systems and facilities, including facilitating coordination and communication channels.

What you'll need:

• Actively licensed in the state of Massachusetts and able to obtain licensure in other states/markets (GA/NC) as this fully virtual role and coverage requires.
• 5 years of RN experience with at least 1 year care coordination/case management experience.
• Must be commuting distance to a local One Medical Senior Health office.
• Demonstrated experience in complex care settings, senior health, or case management experience (preferred), ideally with understanding of home based care services, hospitals/ SNF and long term care facilities. Knowledge of the local market healthcare community is also preferred.
• Demonstrated skill in chronic disease education and care management, comprehensive clinical assessment and care plan development, coordination across health care settings on behalf of very complex patient needs.
• Advanced knowledge of utilization management/ care management principles.
• A goal-oriented, high energy, passionate perspective with a focus on living organizational values and able to set the tone for a positive work culture.
• Demonstrates outstanding clinical aptitude and critical thinking under pressure, using sound judgment in caring for patient needs. Comfortable operating in ambiguity, uses flexibility and creativity to address challenges.
• Ability to use core coaching and teaching techniques, including motivational interviewing and patient-centered communication to activate and empower patients and families.
• Excellent interpersonal communication skills with a variety of audiences via telephone, in person, and electronic means including exceptional listening skills, ability to use appropriate language and demonstrated writing skills.
• Promote and sustain a culture of safety.
• Understanding of Mac iOS, Google suite.
• Spanish speaking is preferred.

Benefits designed to aid your health and wellness:

Taking care of you today

• Paid sabbatical after 5 and 10 years
• Employee Assistance Program - Free confidential advice for team members who need help with stress, anxiety, financial planning, and legal issues
• Competitive Medical, Dental, and Vision plans
• Free One Medical memberships for yourself, your friends and family
• Pre-Tax commuter benefits
• PTO cash outs - Option to cash out up to 40 accrued hours per year

Protecting your future for you and your family

• 401K match
• Credit towards emergency childcare
• Extra contributions toward maternity and paternity leave
• Paid Life Insurance - One Medical pays 100% of the cost of Basic Life Insurance
• Disability insurance - One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance

This is a salaried, full-time, remote role and must be based commuting distance to a One Medical Senior Health office.

This role will have a varied schedule, including possibility of compressed schedule and alternating weekends.