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19 Jan 2018

Full-Time RN Care Coordinator

Mid Oregon Personnel – Posted by MadrasMadras, Oregon, United States

Job Description

RN Care Coordinator

Essential Duties and Responsibilities (daily tasks may include all or part of list identified below):

• Perform a detailed assessment of Medicare covered lives through standardized visits such as Welcome to Medicare and the Annual Wellness Visit.

• Utilize tools and documents that support a guided care process and collaborate with patient/family toward an effective plan of care. • Assess patient and family’s unmet health and social needs

• Provide effective communications to improve health literacy  Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.

• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.

• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.

• Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.

• Coach patients/families toward successful self-management of their chronic disease.

• Provide mentoring/coaching of other population health and care coordination team members.

• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team members or specialists (e.g. Diabetes Educator).

• Cultivate and support primary care and sub-specialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan including transitions-in-care and referrals.

• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.

• Develop or use systems which prevent errors (e.g. effective medication reconciliation).

• Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly regional workshops, monthly cohort calls with other Care Coordinators and Coach)

Secondary Responsibilities:

• Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.

QUALIFICATIONS: Individuals may be asked to perform a working interview to demonstrate ability to complete tasks. Required: Current license as a Registered Nurse within Oregon

Experience: 3 – 5 years’ experience in a clinical or community health setting performing Care Coordination, Case Management or Home Health services. Previous experience in caring for chronic disease patients required. Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred. Previous experience with health I.T. systems and data reporting preferred.

How to Apply

If this sounds like you, please apply with us today! Visit to complete an application. After you have submitted the application, please call us to schedule an interview. Please be prepared to bring a resume to your scheduled interview. We look forward to hearing from you! To apply for this job fill out our job application.

Job Categories: Caregiving and RN. Job Types: Full-Time. Salary: DOE. Job expires in Endless.

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