What are the responsibilities and job description for the CHN - Transitions of Care for Justice Limited-Duration position at Multnomah County, OR?
Current employees: Please apply through the employee portal to be considered for this opportunity.
Pay Range:
$46.41 - $59.65 Hourly
Department:
Health Department
Job Type:
Limited Duration
Exemption Status:
United States of America (Non-Exempt)
Closing Date (Open Until Filled if No Date Specified):
The Opportunity:
THIS WORK MATTERS!
The Multnomah County Community Health Clinics (part of Integrated Clinical Services) seeks a Limited Duration Transitions of Care - Community Health Nurse (TOC-CHN) to provide complex case management for individuals transitioning from incarceration into primary care. This role focuses on connecting recently released individuals with primary care, MOUD treatment, and community resources through working with clients within 90 days of their planned release. The TOC-CHN collaborates closely with Behavioral Health Case Managers and Peer Support Specialists. The position requires a commitment to advancing health equity, eliminating health disparities, and fostering a respectful work environment for the diverse populations served by the clinic. This aligns with the ANA Code of Ethics' focus on protecting human rights and reducing health disparities.
As the Community Health Nurse Transitions of Care for Justice - Limited Duration other duties will include:
Transition of Care Management - Community Health Nurse
- Comprehensive Transition of Care: Provides full health assessments, goal planning, medication reconciliation and management, and arranges community-based continuity of care, including pre-release registration and appointment scheduling with MCCHC.
- MOUD and Medication Management: Implements evidence-based practices for pre- and post-release MOUD, plans for medication continuity post-release (including the first dose), and oversees the transition of chronic health condition medications from Corrections Health to MCCHC.
- Collaboration and Care Coordination: Conducts jail case management, utilizes the shared EMR, integrates the Patient Centered Medical Home and ACO model, provides health education, and collaborates with the BHCM and Corrections Health providers (including pharmacists and nurse practitioners) to ensure seamless transitions and medication management.
Community Engagement and Outreach
- Facilitates Transitions Beyond Multnomah County: Provides warm hand-offs and referrals to program contacts in neighboring counties for released individuals, assessing needs and triaging for urgent primary care appointments at MCCHC before their transition.
- Supporting Out-of-County Care: Assists with scheduling pre-release telemedicine appointments to establish relationships and registration with primary care providers outside Multnomah County, while staying current on case management best practices.
Inter Department Care Coordination
- Cross-Departmental Collaboration: Requires close coordination with Corrections Health, primary care teams, and external community partners (mental health, substance use treatment) to facilitate referrals and connect individuals to ICS primary care.
- Pre-Release Planning and Registration: Conducts depression and SUD screenings, patient registration (including consents and releases of information), and assists with health goal setting and linkage to primary care and medication management before client release.
- Care Coordination and Referrals: Manages chronic conditions (diabetes, HIV, Hepatitis C), ensures seamless access to long-acting medications, documents referrals in Epic, collaborates with MOUD providers, and facilitates warm hand-offs to CHWs, Eligibility Specialists, and other support staff. Participates in case conferences and Population Health huddles.
Documentation and Quality Improvement
- Timely Documentation and Response: Responds promptly to referrals via Epic, documenting all patient interactions (encounters, calls, etc.) in the electronic health record within established timelines.
- Quality Improvement and Data Collection: Participates in quality improvement activities, utilizes population health strategies and data, collects clinical engagement data, and maintains strict medical record confidentiality in compliance with HIPAA. Includes completing required training within 90 days of hire.
Diversity and Inclusion: At Multnomah County, we don't just accept difference; we value it and support it to create a culture of dignity and respect for our employees. We are proud to be an Equal Opportunity Employer. As a Health Department employee you will create a work culture of respect, trust and understanding for the highly diverse populations the Health Department serves in the office and in the community. Every employee shares the responsibility for promptly bringing to the County's attention conduct that interferes with providing a work environment free of illegal discrimination and harassment.
Multnomah County offers an exceptional benefits package, including employer-funded retirement savings; health and dental insurance at very low cost to full-time employees and their dependents; paid parental leave; wellness programs; a focus on work-life balance; and much more. Find more details on our
benefits website.
Our Commitment to Safety, Trust and Belonging: Multnomah County is committed to developing, nurturing and continually improving workforce equity by identifying and addressing the structural and policy barriers to equal employment opportunity faced by our employees and communities. County employees across the organization have stepped forward to develop a strategic plan and help create a workplace where everyone can reach their full potential. Learn more by reading our
Workforce Equity Strategic Plan
and exploring our Core Competencies
for all County employees.
TO QUALIFY:
We will consider any combination of relevant work experience, volunteering, education, and transferable skills as qualifying unless an item or section is labeled required. Please be clear and specific about how your background is relevant. For details about how we typically screen applications, review our overview of
the selection process
page.
Minimum Qualifications/Transferable Skills*:
Any combination of experience and training that would likely provide the knowledge and abilities is qualifying. A typical way to obtain the knowledge and abilities would be as noted below. All non-traditional education, training and experience will be evaluated.
Education/Training:
- An Associate's degree or a Bachelor's degree in nursing from an accredited nursing program
- Registered Nurse Licensure
Experience/Certification:
- BLS CPR Certification
- Oregon license through State Board of Nursing
Preferred Qualifications/ Transferable Skills*: You need to have the following preferred qualifications/ transferable skills to qualify. However, keep in mind we may consider some or all of the following when identifying the most qualified candidates. Please clearly explain on your application how you meet any of the following preferred qualifications/transferable skills.
- Experience in Corrections Health, and/or Case Management.
- Working with Justice Involved Clients.
- Working with clients who have SUD, MH challenges, and/or chronic diseases requiring medication adherence support.
- Epic experience is required.
- Transferable skills: Your transferable skills are any skills you have gained through education, work experience (including the military) or life experience that are relevant for this position. Be sure to describe any transferable skills on your application and clearly explain how they apply to this position.
SCREENING & EVALUATION:
REQUIRED:
The Application Packet: You must submit all requested items below. Failure to do so will be deemed as an incomplete application.
1. Attach a Resume demonstrating you meeting minimum qualifications; AND
2. Attach a Cover Letter addressing the following:
- Demonstrate your experience working with diverse vulnerable populations; and
- How you meet the qualifications for this position; and
- Why you are interested in the position
Note: The application, resume and cover letter should clearly demonstrate your work experience/skills and how they relate to the descriptions provided in the ‘Overview’ and ‘To Qualify’ sections of the job announcement. Please be thorough, as these materials will be scored and determine your eligibility to advance in this recruitment process.
After You Apply:
- Please save a copy of this job posting for your reference, as it will not be available for you to view online after the job posting closes.
- Log in to your Workday account before the job posting closes to see if you have any pending tasks or actions to complete. These can be found under the “My Applications” section. You must complete these tasks or actions before the job posting closes.
- Check both your email and Workday account for updates regarding this recruitment.
The Selection Process: For details about how we typically screen applications, review our overview of
the selection process
page. We expect to evaluate candidates for this recruitment as follows:- Initial review of minimum qualifications
- Resume and Cover Letter Review
- Phone screen
- Consideration of top candidates
- Language assessment
- Background, reference
Note: Application information may be used throughout the entire selection process. This process is subject to change without notice.
Future Opportunities: Applying for this posting will give you the opportunity to be placed on the eligible list for future positions as they become available. The eligible list created from this recruitment may be used to fill regular, full or part time, temporary, on call and limited duration assignments.
Salary / Equal Pay Law: Please be advised that the pay range listed for this position is intended to provide general guidance on the earning potential for the role. However, actual compensation will be determined in accordance with the Oregon Equal Pay Law and will take into account factors such as the candidate's relevant experience and education. Candidates should expect that initial offers will be made within the listed pay range and may not be at or near the top of the range.
Inclement Weather and Disasters - Serving the Public, Even During Disasters:
Everyday, Multnomah County staff work together to serve as a safety net for our communities. During a disaster, this safety net becomes even more critical. All County employees have a role in serving the public during inclement weather, natural disaster, or other types of community emergency response. During these emergency responses, while typically there begins with a call for volunteers, county employees may ultimately be reassigned from their current position to a role in the emergency response in order to support the critical needs presented by our communities. For more information, please visit the
Disaster Service Worker Information
page.
ADDITIONAL INFORMATION:
Type of Position: This position is eligible for overtime.
Type: Represented by ONA
FLSA: Non-Exempt
Location: East County-Primary Location (all clinic locations) plus remote
Schedule: Monday - Friday 8am - 5pm
Diversity and Inclusion: At Multnomah County, we don't just accept difference; we value it and support it to create a culture of dignity and respect for our employees.
We are proud to be an Equal Opportunity Employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran or protected veteran status, genetic information and other legally protected characteristics. The
EEO Know Your Rights poster
is available for your reference. Multnomah County is a VEVRAA Federal Contractor. We request priority protected veteran referrals.
Veterans’ Preference: Under Oregon Law, qualifying veterans may apply for veterans’ preference. Review our
veterans’ preference page
for details about eligibility and how to apply.
Accommodation under the Americans with Disabilities Act: We gladly provide reasonable accommodation to anyone whose specific disability prevents them from completing an application or participating in this recruitment process. Please contact the recruiter below in advance to request assistance. Individuals with hearing or speech impairments may contact the recruiter through the Telecommunications Relay Service by dialing 711.
Questions?
Recruiter:
Christopher Bogan
Email:
christopher.bogan@multco.us
Phone:
1 (971) 4389901
Application information may be used throughout the entire selection process. This process is subject to change without notice.
Disclaimer: This announcement is intended as a general descriptive recruitment guide and is subject to change. It does not constitute either an expressed or implied contract.
Job Profile:
6315 - Community Health NurseSalary : $46 - $60
