Virtual RN Care Coordinator

The Opportunity

The One Medical at Home (OM@H) Program is seeking an experienced, Remote, full-time Registered Nurse with a Care Management or Case Management background to join our team. This is a fully virtual role supporting patients in multiple states/markets. The OM@H RN will support the care of One Medical Senior Health patients enrolled in the OM@H program by working with internal and external care team members to coordinate patient care.  The OM@H RN will create appropriate action plans, triage patient phone calls, and manage transitions of care to acute and post acute facilities. 

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.  

Employment type:

• Full time
• 40 hours per week
• Must reside in Washington or the West Coast
• Must be able to work Monday through Friday, 8AM - 5PM in the Pacific Time Zone

What you’ll be working on:

• Participate in daily huddles and weekly rounding with your assigned market care teams to review overnight calls, previous day triages, complex patient care needs, new facility admissions, pending facility discharges, and provider daily schedules.
• Address tasks assigned to you by various team members for your patient panel including, but not limited to, lab results, medication questions, short term education needs, action plan requests, and triage follow up.
• Work together with other RNs to respond to incoming patient calls across all markets that require nursing triage
• Respond timely to multiple Slack channels where team members post urgent needs throughout the day 
• Serve as the primary liaison between partner providers and the patient’s primary care physician (PCP) team during time of transition, engaging in action 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-action 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 care coordination rounds and team huddles 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.

Education, licenses, and experiences required for this role:

• WA Licensed Registered Nurse (RN) required and ability to obtain licensure or already be licensed in other states/markets (GA, TX, AZ, CO) as this fully virtual role and coverage requires it.
• 5+ years of RN experience with at least 1 year care coordination/case management experience within the past 5 years.
• 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.

One Medical providers also demonstrate:

• A passion for human-centered primary care for our senior members
• The ability to successfully communicate with and provide care to individuals of all backgrounds   
• The ability to effectively use technology to deliver high quality care
• The desire to be an integral part of a team dedicated to changing healthcare delivery
• An openness to feedback and reflection to gain productive insight into strengths and weaknesses
• The ability to confidently navigate uncertain situations with both patients and colleagues
• Readiness to adapt personal and interpersonal behavior to meet the needs of our patients

This is a full-time virtual role.