Description

The RN Care Coordinator functions as the clinic care team RN, and provides support to patients and care plan management utilizing the nursing process. The goal is to provide individualized education, coaching and follow-up to improve patients’ self-management skills. Interventions are intended to help patients and patient populations adhere to treatments and maintain their quality of life with chronic diseases and/or complex illnesses. The RN Care Coordinator provides direct patient care and also facilitates the coordination of care between others involved in the care of the patient, including the patient's primary care team, medical specialists, hospitals, and health plans.

Patient Care and Care Coordination

• Coordinate the care of complex patients using evidence-based practice

• Transitional care management (coordinate ER and hospital follow up as well as care setting transitions)

• Perform medication reconciliation for moderate/high-risk patients post-discharge from inpatient setting

• Develop and manage care plans in collaboration with the primary care providers and other members of the care team

• Participate in and/or lead team huddles

• In individual or group settings, provide patient and family member education on chronic disease management, acute conditions, and preventive health behaviors

• Use motivational interviewing to support health goal-setting

• Demonstrate proficiency and act as an expert role model in the performance of patient care

• Utilize standing orders to manage the care of patients

• As a templated provider, see scheduled patients for nurse-led visits, including but not limited to diabetes and chronic disease education and management, pregnancy and women’s health-related visits, anticoagulation management, basic wound care

• Perform patient outreach and/or follow-up as directed

• Provide direct patient care in any clinical role within scope of practice and current competencies, including in-person and telephone triage

• Serve as a clinical support resource for Medical Assistant staff and other care team members

• Provide in person and/or remote coverage at other clinic sites on an as-needed basis; travel within the Mosaic service area

• Deliver patient care within HRSA services scope and approved locations, encompassing patient homes, community-based sites, and providing home-based care when necessary and in adherence to defined services and safety protocols. Local travel required.

• Document all interactions in the EHR in a timely, thorough, and accurate manner

Skills & Knowledge

• Required: Superior nursing process skills. Critical thinking and problem solving skills. Excellent written, verbal, telephone and interpersonal communication skills. Familiarity/experience with client interaction on the telephone. Knowledge of community resources. Basic typing and computer skills and comfort with Microsoft Windows operating system.

• Preferred: EHR experience - EPIC experience a plus. Fluency in Spanish preferred. Involvement with quality improvement processes. Knowledge of health insurance plans, standard office policies and procedures as well as regulatory requirements including CLIA and OSHA standards.

Who We Are:

Mosaic Community Health prides itself on being an innovative health system that pioneers unique and creative ways to provide and improve patient access to health care. Since our founding in 2002 we have proudly served insured and uninsured patients regardless of age, ethnicity, or income.

We focus on a holistic approach to patient care by incorporating behavioral health, pharmacy, and nutrition support to serve patients in the most meaningful way. At Mosaic Community Health, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team based environment.

Mosaic Community Health offers more than just a job, it is a lifestyle. A lifestyle of serving others. A lifestyle of being an integral part of your community. A lifestyle that offers work/life balance. A lifestyle of enjoying the outdoors! Central Oregon offers over 300 days of sunshine a year, so enjoy a PTO day on the mountain, biking/hiking trails, or the river! A lifestyle that improves lives, including yours. Of course, we also offer a great benefit package!

Qualifications

Education

Preferred

• Bachelors or better in Nursing

Licenses & Certifications

Required

• CPR

• Driver's License

• Registered Nurse

Experience

Required

• 2 years: Minimum two years of RN clinical experience in acute or ambulatory care required. Care coordination experience in an ambulatory setting preferred. Experience in nurse-led patient visits preferred (i.e. diabetes and chronic disease education, anticoagulation management)