Chronic Care Coordinator - Strawberry Wilderness Community Clinic | Part Time

Position Summary

The Chronic Care Coordinator will work in a collaborative role with the Medical Director, Clinic RN, Medical Assistants, and Clinic Director to provide personalized care to individuals managing chronic illness. They will be collaborating closely with patients, families, and healthcare professionals to implement tailored care plans and optimize health outcomes to enhance quality of life for those facing long-term health challenges.

Essential Functions and Responsibilities

• Promotes the mission, vision, and values of the BMHD.
• Collaborates with providers and clinic staff on quality improvement initiatives.
• Diabetic Management and Instruction.
• Triage assessments with communications between hospital/clinic.
• Conduct comprehensive assessments of patients with chronic illnesses, including medical history, current symptoms, and psychosocial factors.
• Develop individualized care plans in collaboration with patients, families, and healthcare providers, focusing on disease management, symptom control, and lifestyle modifications.
• Monitor and evaluate patients’ health status, response to treatment, and adherence to care plans on an ongoing basis.
• Provide education and support to patients and families regarding their condition, treatment options, medications, and self-management strategies.
• Coordinate care and facilitate communication between healthcare providers, specialists, and community resources to ensure continuity of care.
• Advocate for patient’s needs and rights, addressing barriers to access healthcare services and promoting patient-centered care.
• Utilize evidence-based practices and clinical guidelines to deliver high-quality, cost-effective care and achieve optimal patient outcomes.
• Performs Annual Medicare Wellness Visits in conjunction with providers.
• Document patient assessments, interventions, and outcomes accurately and timely in electronic health records (EHR) or other designated systems.
• Participate in quality improvement initiatives, research projects, and professional development activities to enhance clinical practice and promote innovation in chronic care management.

Knowledge, Skills and Abilities

• Maintains self-motivation and sustains a high level of momentum.
• Able to successfully prioritize when faced with requests, demands and deadlines.
• Knowledge of customer service concepts.
• Must be extremely detail-oriented and able to keep organized records.
• Proven ability to communicate effectively, both in written and oral form.
• Ability to communicate effectively in English, both verbally and in writing.
• Proven ability to work as part of a team, in a fast-paced production-oriented environment.
• Expresses excellent judgment, discretion, and decision-making abilities.
• Maintains a sensitive, fair and impartial approach to dealing with employees.
• Supports and maintains a culture of safety, quality and positive patient experience.
• Working knowledge of relevant regulatory requirements, CMS, National Patient Safety Goals (NPSGs), and continued readiness related to healthcare or hospital standards.
• Ability to prioritize, highly organized.

Education Requirements

Required:

• Associate Degree in Nursing

Preferred:

• BSN

• Understanding of CMS regulations regarding rural health clinics.

  Working experience in critical access hospital setting.

Certification/Licensure Requirements

• Basic Life Support (BLS) certified by American Heart Association (AHA). MUST obtain within 60 days of hire.
• RN License, in good standing with State of Oregon
• Valid Permit or Driver’s License

For More Information, Contact

Holly Thompson, Human Resources
| 541-575-3820

Why Blue Mountain Hospital District & Grant County?

The Blue Mountain Hospital District (BMHD) is located in Grant County, Oregon, at the heart of the John Day River, in beautiful, rural, Eastern Oregon. Our District is comprised of a Critical Access Hospital (CAH), Family & Rural Medicine Clinic, Home Care and Hospice, Emergency Medical Services, an Intermediate Care Center and all of the supporting ancillary departments necessary to care for the health and wellness of our community.

Our District spans from John Day to Prairie City, nestled in a valley surrounded by the Blue Mountains. The Strawberry Mountain Range and John Day River Valley offers a variety of outdoor activities, from abundant hiking/mountain biking/horse riding trails to high and low lakes and ponds. Our area is known to be a “go to” place not just for recreation, but also for big game hunting and fishing!

Join our family-like team and settle into a lifestyle that is hard to beat!

For more information on our area, visit our Grant County Chamber of Commerce and Discover John Day pages at: and