RN High Risk Care Manager Senior

Summary

Join One Medical's High Risk Programs as a full-time, virtual Registered Nurse on the Transitions of Care team. You will provide transitional case management to senior patients, coordinating care with internal and external teams. Responsibilities include creating care plans, managing patient needs, addressing post-discharge barriers, and communicating with healthcare providers. This role requires a WA RN license (with ability to obtain others), 5+ years of RN experience, including 1 year of care coordination/case management. Demonstrated skills in chronic disease education, care management, and clinical assessment are essential. Excellent communication and interpersonal skills are also required. One Medical offers a comprehensive benefits package, including health insurance, retirement benefits, paid time off, and more.

Requirements

• WA Licensed Registered Nurse (RN) required and ability to obtain licensure in other states/markets as this fully virtual role and coverage requires
• 5+ years of RN experience with at least 1 year care coordination/case management experience within the past 5 years
• 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

Responsibilities

• Provide transitional case management to a revolving panel of Senior patients; working with patients, families, providers, and healthcare facilities to improve clinical outcomes and help reduce readmissions to acute care settings
• Interact with internal and external care team members to provide complex coordination for patients needing short-term case management and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments
• Serve as the primary liaison between partner providers and the patient’s primary care physician (PCP) team during time of transition, engaging in care 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-care 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 case conferences and team huddles as appropriate 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

Preferred Qualifications

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

Benefits

• Paid sabbatical for every five years of service
• Free One Medical memberships for yourself, your friends and family
• Employee Assistance Program - Free confidential services for team members who need help with stress, anxiety, financial planning, and legal issues
• Competitive Medical, Dental and Vision plans
• Pre-Tax commuter benefits
• PTO cash outs - Option to cash out up to 40 accrued hours per year
• 401K match
• Credit towards emergency childcare
• Company paid maternity and paternity leave
• Paid Life Insurance - One Medical pays 100% of the cost of Basic Life Insurance
• Disability insurance - One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance
• Malpractice Insurance - Malpractice fees to insure your practice at One Medical is covered 100%
• UpToDate Subscription - An evidence-based clinical research tool
• Continuing Medical Education (CME) - Receive an annual stipend for continuing medical education
• Rounds - Providers end patient care one hour early each week to participate in this shared learning experience
• Discounted rate to attend One Medical’s Annual REAL primary care conference