Description
**Explore opportunities at The Corvallis Clinic, part of the Optum family of businesses.** For more than 75 years, our multi-specialty group has been committed to delivering exceptional care to our patients and fulfilling careers to our team members. As a leading clinic in Oregon's mid-Willamette Valley, we serve more than a quarter-million people with offices in Corvallis, Albany and Philomath. Join a team that empowers you from the start and values work-life balance, teamwork and trust. We offer comprehensive benefits and competitive pay. Elevate your career with us and discover the meaning behind **Caring. Connecting. Growing together.**
The RN Care Coordinator collaborates to provide education and support for social determinants of health and assists with managing high risk patients by assessing needs, developing, and implementing care-plans, and coordinating services. This RN also supports patients with a variety of mental health diagnoses in finding mental health resources. The RN Coordinator maintains the adequacy of the care-plan, advocates for the patient and family throughout the healthcare realm, and proactively works within the healthcare team to keep the patient as healthy as possible. The RN innovates and assists in the development of new programs, such as educational programs for chronic conditions, and develops initiatives to reduce ED utilization and Hospital Readmission. The RN works independently and as part of the Care Coordination team with the primary care providers and their patients at the Corvallis Clinic Asbury Building.
If you are located in Corvallis, Oregon, you will have the flexibility to Work from home and the office in this hybrid role* as you take on some tough challenges.
**Primary Responsibilities:**
Participates and maintains a culture within The Corvallis Clinic that is consistent with the content outlined in the Service and Behavioral Standards document. To this end, employee will be expected to read, have familiarity, and embrace the principles contained within
Works within the interdisciplinary team as part of our Patient Centered Primary Care Medical Home and collaborate with existing team of RN Care Coordinators
Provides nursing care according to the sequential steps of the nursing process: assessment, planning, intervention, implementation, and evaluation
Develops and implements new programs as needed
Assists with development and communication of clinical changes defined by Primary Care First and other Quality contracts
Reviews inpatient utilization and discharge planning daily. Reviews notes faxed from hospital or SNF, assesses patients, and communicates issues to healthcare team
Provides or arranges for early intervention to avoid hospitalization of high-risk patients and arrange for community support services and equipment. Interfaces with the providers, family, patients, and/or caregivers as appropriate
Provides or arranges for follow up mental health care and navigation of resources
Provides or arranges for follow up care with Home Health Services, Skilled Nursing Facility (SNF) services and subsequent discharge planning. Conducts ongoing concurrent review by reviewing SNF Rehabilitation meeting notes and frequent phone contact
Coordinates care for patients starting on hospice or palliative care
Contacts patients after discharge from hospital or other inpatient facility to ensure discharge needs have been met, assess for readiness to be home, reconcile medications, and to coordinate follow up with primary care and other specialties. Contact patients within 2 days of discharge
Reviews emergency department utilization and discharge planning daily. Reviews notes from hospital and communicates issues to healthcare team. Educate patients about alternatives to the emergency department. Contact patients within 7 days of ED visit
Participates in initiative to reduce ED utilization and assists in tracking these patients
Makes appropriate referrals to health plans and ensure the coordination of patient services and accuracy of reported data
Works with individual providers to facilitate changes in practice patterns, when appropriate as directed by the Clinical Director or Manager
Meets weekly with select primary care teams to review hospitalization and ED use, care coordination for high-risk patients, quality data, and to educate about new initiatives
Improves the quality of care through continuing education and self-evaluation of the effectiveness of care. This includes attendance/participation in most in-services/department meetings and remaining current on clinic/department policies and procedures
Participates in orientation and training of new employees
Works with patients individually and in the group setting
Collaborates with primary care providers by attending patient appointments, receiving "warm hand-offs," and attending weekly primary care huddles.
Completes individual patient Care Plans for home clinic to meet requirements of Medical Home
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
**Required Qualifications:**
Graduate of an accredited school of registered nursing
Current unencumbered State of Oregon license as a Registered Nurse
Current Basic Life Support (BLS) certification or ability to complete BLS certification within 90 days of hire
1+ years of nursing experience
**Preferred Qualifications:**
Case Management certified or willingness to obtain within 2 years of employment
Evidence of working knowledge of the nursing process
Adaptability/flexibility & time management
Customer service and the ability to work well both independently and as a member of a multidisciplinary team
Ability to work on multiple tasks simultaneously in a busy, fast-paced environment while maintaining quality of work
Knowledge of chronic health conditions and their greater impact
Self-starter, motivated, and accountable
Ability to communicate effectively in both written and verbal formats
Ability to identify complex problems, review information, and navigate to reasonable solutions
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
-At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to
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