Registered Nurse (RN) - Med Surg
Indian Health Service
Portland, OR

Nurse Care Coordinator

Locations: Portland, OR Type:Urban Salary Range:$40 to $45 / Per Hour Open Period:11/5/2024 to 12/31/2024 Summary:If you are a motivated and dedicated Registered Nurse looking for an opportunity to contribute to an organization making a positive impact, we want to hear from you! At NARA NW, you'll find a supportive and inclusive work environment where every member of our team is valued and respected. Whether you're passionate about healthcare, behavioral health, education, or social services, there's a place for you to make a positive impact. Company Mission: The mission of NARA NW is to provide education, physical, mental health services, and substance abuse treatment that is culturally appropriate to American Indians, Alaska Natives, and anyone in need. About the Company: At NARA NW, we provide essential services and support to Native American and Alaska Native people, empowering them to lead healthy, fulfilling lives. As an organization rooted in cultural heritage and community values, we offer a unique and rewarding opportunity to make a direct positive impact in the lives of others. We have over 400 employees in a wide range of programs and services, including medical and dental care, addiction treatment, housing assistance, and cultural enrichment programs, there are endless opportunities to grow and thrive in your career while making a difference in the lives of others. Position Overview: The Registered Nurse (RN) Care Coordinator is part of an innovative, community-based team that strives to provide culturally specific Care Coordination. This position works collaboratively with American Indian or Alaskan Native members who may have complex medical/psychosocial/ addiction issues and their families/caregivers as well as with members of multidisciplinary teams (MDT) to help members transition from acute care to their community care setting and provide medical based care coordination. Using culturally sensitive evidence-based transitions interventions, the RN Care Coordinator will engage members and providers across the care continuum to identify and address risks associated with hospital readmission and barriers to care. This position will engage with members telephonically and in-person, in the hospital and clinic settings, members' homes and/or community settings. The RN Care Coordinator is part of an advanced illness initiative which aims to improve quality of care, coordinate care across the continuum, reduce hospital readmissions, and increase access to end of life care. Duties:What you will do: Provides coordination of care, benefits, community resources and referrals to facilitate safe transitions between care settings. Responsible for scheduling for patients discharging the hospital or inpatient settings Uploads discharge paperwork into the EHR Coordinates/updates the plan of care that includes self-management and member specific goals. Unlike other nursing roles, this role does not direct or lead the care planning process; rather, it contributes to a multidisciplinary care planning process. Collaborates with members of multidisciplinary medical teams to provide a process that enhances patient satisfaction, efficiency of time and resources, and improved outcomes. Uses evidence-based approaches to patient education regarding member's health status, disease state, red flag symptoms, symptom management, medication management and self-management strategies. Utilizes evidence-based guidelines and best practices related to disease-specific assessment and interventions. Collaborates with care managers, multidisciplinary providers, benefit specialists, behavioral health specialists, pharmacists, vendors, and social services to enhance member satisfaction, conserve time and resources, identify barriers, improve outcomes and reduce avoidable readmissions. Plans, participates in, and facilitates care conferences for medically complex members and others as deemed appropriate (including the clinic discharge process). Coordinates the plan of care, assesses member's stability and ability to adhere to the prescribed treatment and self-management plan. Incorporates member's right to choice of treatment or refusal of treatment. Works with members effectively in the home setting as appropriate to assess safety and coordinate services to address needs or opportunities to promote wellness. Establishes a trusting relationship with the member, their family and other relevant parties involved to facilitate access to needed services to meet health needs. Assesses the needs of each member, advocates as appropriate and links member to needed services using stewardship principles and following organizational policies. Creatively utilizes available community resources as an adjunct to health plan benefits and follow-up to determine if these are received by the member. Involves Medical Director for situations that appear to warrant medical director assistance or review. Assists in mentoring newly hired staff Qualifications:Current unencumbered Oregon RN license Washington RN license within 90 days Minimum 2 years' clinical experience with direct patient care as an RN Bachelor's degree in nursing Work Type:Permanent, Full