RN Patient Care Coordinator

Position Details

• Employment Status: Full-Time

• Position Status: Hybrid

• Weekly Hours: 40

Compensation: $33.30 - $41.65 per hour (depending on years of experience)

Summary:

The RN Care Coordinator collaborates to provide education and support for social determinants of health and assists with managing high risk patients by assessing needs, developing, and implementing care-plans, and coordinating services. This RN also supports patients with a variety of mental health diagnoses in finding mental health resources. The RN Coordinator maintains the adequacy of the care-plan, advocates for the patient and family throughout the healthcare realm, and proactively works within the healthcare team to keep the patient as healthy as possible. The RN innovates and assists in the development of new programs, such as educational programs for chronic conditions, and develops initiatives to reduce ED utilization and Hospital Readmission. The RN works independently and as part of the Care Coordination team with the primary care providers and their patients at the Corvallis Clinic Asbury Building.

Principal Responsibilities:

1.Will participate and maintain a culture within The Corvallis Clinic that is consistent with the content outlined in the Service and Behavioral Standards document. To this end, employee will be expected to read, have familiarity, and embrace the principles contained within.

2.Works within the interdisciplinary team as part of our Patient Centered Primary Care Medical Home and collaborate with existing team of RN Care Coordinators.

3.Provides nursing care according to the sequential 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 of clinical changes defined by Primary Care First and other Quality contracts.

6.Reviews inpatient 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 to avoid hospitalization of high-risk patients and arrange for community support services and equipment. Interface with the providers, family, patients, and/or caregivers as appropriate.

8.Provides or arranges for follow up mental health care and navigation of resources.

9.Provides or arranges for follow up care with Home Health Services, Skilled Nursing Facility (SNF) services and subsequent discharge planning. Conducts ongoing concurrent review by reviewing SNF Rehabilitation meeting notes and frequent phone contact.

10. Coordinates care for patients starting on hospice or palliative care.

11. Contacts patients after discharge from hospital or other inpatient facility to ensure discharge needs have been met, assess for readiness to be home, reconcile medications, and to coordinate follow up with primary care and other specialties. Contact patients within 2 days of discharge.

12. Reviews emergency department utilization and discharge planning daily. Reviews notes from hospital and communicates issues to healthcare team. Educate patients about alternatives to the emergency department. Contact patients within 7 days of ED visit.

13. Participates in initiative to reduce ED utilization and assists in tracking these patients.

14. Makes appropriate referrals to health plans and ensure the coordination of patient services and accuracy of reported data.

15. Works with individual providers to facilitate changes in practice patterns, when appropriate as directed by the Clinical Director or Manager.

16. Meets weekly with select primary care teams to review hospitalization and ED use, care coordination for high-risk patients, quality data, and to educate about new initiatives.

17. Improves the quality of care through continuing education and self-evaluation of the effectiveness of care. This includes attendance/participation in most in-services/department meetings and remaining current on clinic/department policies and procedures.

18. Participates in orientation and training of new employees.

19. Works with patients individually and in the group setting.

20. Collaborates with primary care providers by attending patient appointments, receiving "warm hand-offs," and attending weekly primary care huddles.

21. Completes individual patient Care Plans for home clinic to meet requirements of Medical Home.

Education, Licensure and Experience:

1.Graduate of an accredited school of registered nursing and one (1) year of nursing experience required.

2.Current unencumbered State of Oregon license as a Registered Nurse required.

3.Case Management certified or willingness to obtain within 2 years of employment required.

4.Current Basic Life Support (BLS) certification or ability to complete BLS certification within 90 days of hire required.

Knowledge and Skills:

1.Evidence of working knowledge of the nursing process

2.Adaptability/flexibility & time management

3.Customer service and the ability to work well both independently and as a member of a multidisciplinary team

4.Ability to work on multiple tasks simultaneously in a busy, fast-paced environment while maintaining quality of work

5.Knowledge of chronic health conditions and their greater impact

6.Self-starter, motivated, and accountable

7.Ability to communicate effectively in both written and verbal formats

8.Ability to identify complex problems, review information, and navigate to reasonable solutions

Perks and Benefits:

• Work-life balance is a top priority at The Corvallis Clinic

• 7 holidays + 2 floating holidays = 9 Paid Holidays! Early release on Christmas Eve and New Year's Eve

• Generous Personal Leave Accrual

• Benefits: Medical w/ HSA or HRA, Dental, Flexible Spending Acct (FSA)

• Employer contribution to HSA and HRA (when enrolled in Medical Plan)

• Employer paid Long Term Disability (LTD), Basic Life/AD&D, Employee Assistance Program (EAP)

• Voluntary Benefits (Vision, Life Insurance and AD&D, Pet Insurance, Aflac, Legal Shield)

• Retirement - 401k eligible and auto enrolled after 90 days, 100% vested from day 1, with discretionary clinic match after 1 year (w/hours requirement) and discretionary Profit Share after 2 years (w/hours requirement).

• Pay on Demand (up to 2x per month)

• Casual Fridays (with clinic approved attire)

• Year-round employee engagement events and festivities

• Team centered culture, delivering exceptional medical care with compassion and a commitment to service.