Registered Nurse (RN) - Med Surg
Native American Rehabilitation Association of the Northwest, Inc
Portland, OR

Nurse Care Coordinator

Title: Registered Nurse Care Coordinator Location: 12360 E Burnside St. Portland, OR 97233 Schedule: This is an in person position, Monday through Friday 8:30am-5pm. Wage Range: $40.00 - $45.00, non-exempt 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. 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; provides coaching and training on specific job responsibilities. * Manages an efficient and effective case load. * Reports to work as scheduled and follow attendance policies; maintain agreed upon work schedule. * Effective at establishing and maintaining key community partnerships. * Participates in work related to continuing education when offered or directed. * Proposes and implements process improvements. * Meets deadlines for completion of daily, weekly and month-end reporting. * Demonstrates cooperation and teamwork. Qualifications We would like to hear from people that have: * 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 * RN experience in home care, advanced illness, palliative care, hospice, primary care, and/or case management * Ability to operate independently with minimal supervision. * Ability to communicate effectively and confidentially with external and internal contacts. * Ability to make medically sound, accurate, fast, independent decisions. * Knowledge of the impact of trauma, generational poverty and social determinants of health on the members' ability to develop and follow self-care goals to improve health outcomes * Comfortable supporting members at the end of their lives; including facilitating advanced care planning * Ability to be sympathetic to a member, family or caregivers needs, and be able to deal with people in various states of pain, trauma and tragedy * Knowledge of community resources to support a complex, vulnerable population * Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying a member's multidisciplinary needs, developing health goals and communicating with providers * Ability to work with members from various cultural and ethnic backgrounds; demonstrating cultural knowledge and sensitivity to populations being served * Ability to work independently * Adaptable in fast paced environments, has excellent time management skills and demonstrates flexibility in operating in different work settings with superb attention to detail * Able to initiate and answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information * Excellent verbal and written communication skills * Strong computer skills and knowledge of medical HER, Microsoft Outlook and Office (Word, Excel) * Possess a high degree of initiative and motivation along with the ability to effectively communicate and collaborate with coworkers and others. * Ability to pass a pre-employment or for cause drug tests. * Ability to pass criminal background and DMV checks. * Valid driver's license, acceptable driving record, and automobile liability coverage or access to an insured vehicle Preferred Qualifications: * Ability to pass criminal background and DMV checks. * Valid driver's license, acceptable driving record, and automobile liability coverage or access to an insured vehicle * Experience with utilization of motivational interviewing and trauma informed care * Specialized training in Evidence Based Practices providing behavioral changes * Experience working with diverse populations that have experienced obstacles and barriers associated with marginalization either in mental health and/or addictions work * Experience working with Tribal communities and intergenerational trauma * Have or be willing to learn specific knowledge of specific needs of gender affirming care, resources available to this population and an understanding of unique needs of the transgender experience What's in it for you? 15 Paid Holidays: New Years, Martin Luther King Day, Presidents Day, Memorial Day, Juneteenth, Battle of Little Big Horn, 4th of July, Labor Day, United Indigenous Day, Veterans Day, Thanksgiving, Day after Thanksgiving, Christmas, and Employee's Birthday! Benefits: Employees working 20 hours, or more are eligible for benefits. Benefits are effective from the 1st of the month following the date of hire. * Affordable Medical, Dental, and Vision Insurance through Kaiser Permanente * 14 Paid Federal Holidays (Listed Above) * 13 Paid Days of Sick Time * 13 Paid Days of PTO (Vacation accruals increase with years of service to a maximum of 26 days) * $50,000 Life Insurance & AD&D * Short Term and Long-Term Disability * Flexible Spending Account * Health Spending Account * 401(k) with 4% Match * Employee Assistance Program * Inclement Weather Days (Snow Days) * Referral Program- (Up to $1000 Dollars) * Company Phone * Company Laptop * Public Student Loan Forgiveness -NARA NW is a local 501(c)3 nonprofit, FQHC How to apply: * To Quick Apply, go to Careers - NARA NW (naranorthwest.org) * Look for the position you want to apply for and submit a resume (Required) and cover letter (Not required), that's all! * Feel free to contact [email protected] if you have any questions or would like to know where your application is in the process. NARA NW is fully committed to supporting sobriety. All employees must agree to model sobriety, including no alcohol drinking, no illicit drug use, no marijuana use, and no prescription drug abuse behavior. If in recovery, must have been sober/clean for a length of time sufficient to demonstrate that will be able to model sobriety.. This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills or working conditions associated with the position. While it is intended to accurately reflect the position's activities and requirements, the agency reserves the right to modify, add or remove duties and assign other duties, as necessary. Preference in hiring is given to qualified Native Americans in accordance with the Indian Preference Act (Title 25, US Code, Sections 472 and 473). NARA Northwest is an Equal Opportunity Employer. Within the scope of Indian Preference, all candidates will receive equal consideration. Experience working with Native American/ Alaska Native community is considered a plus.