RN Care Coordinator & Triage - Dual Role

The RN Care Coordinator (RNCC) 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 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.The Triage RN is responsible for ensuring patients receive timely, appropriate care by overseeing and performing clinical assessments, health education, and determining and facilitating appropriate clinical dispositions. This RN will also perform additional patient outreach and / or follow-up as required. This position is primarily a phone-based nursing role.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.Patient Care- TriagePerform telephone triage and assess patient health condition using the Nursing Process.Effectively utilize decision support tools and approved protocols to provide patient care over the phone.Develop, implement, and evaluate a plan of care for each encounter.Resolve patient issues / concerns and / or route to appropriate staff.Disposition patients to appropriate levels of care.Consult and coordinate with healthcare team members including, but not limited to; primary care providers, nursing, medical assistants, etc. to optimize care.Document all interactions in the EHR in a timely, thorough, and accurate manner.Educate patients about available Mosaic and community resources.Perform emergency department follow-up assessment calls.Receive, review, forward, and / or follow-up on Outside Event notifications.Perform additional patient outreach and / or follow-up calls.Provide patient care in any clinical role within scope of practice and current competencies.Provide occasional on-site coverage at clinics; travel within the Mosaic service area on an as needed basis.Respond to MyChart messages within required timeframe.Supporting Job ResponsibilitiesRN Care Coordinator : Room patients, perform tests and collect and / or process specimens.Attend meetings, team huddles and assigned trainings.Participate in quality improvement efforts and initiatives.Address in a timely manner, correspondence which includes but is not limited to Outlook, EHR encounters, in-basket, etc.Utilize resources to remain informed of organizational communication (i.e. Mosaic Share, organization newsletter, etc.).Comply with all policies, procedures, guidelines, and workflows.Perform safe work practices to protect the health and safety of employees and patients per OSHA regulation.Protect individually identifiable health information per HIPAA regulation.Complete all required compliance training within the established timeline.Utilize the incident reporting system as needed.Triage : Attend meetings, team huddles and assigned trainings.Participate in quality improvement efforts.Address in a timely manner, correspondence which includes but is not limited to Outlook, EHR encounters, in-basket, etc.Utilize resources to remain informed of organizational communication (i.e. Mosaic Share, organization newsletter, etc.).Comply with all policies, procedures, guidelines, and workflows.Work Experience : 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). In-person and / or Telephone Triage experience preferred. Experience in the care of adult and pediatric populations preferred.Courtney Clinic RNCC : In addition to the above, experience in the care of prenatal patients preferred. Experience in the care of opiate use disorder patients preferredPediatric RNCC : Experience working with pediatric patients preferredEducation, certification and licensure : Required : Associates degree; Current, unrestricted Oregon RN License; BLS / CPR Certification; Valid Oregon State driver's licensePreferred : Bachelor of Science in Nursing (BSN)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 AreMosaic 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.