RN Care Coordinator

Nehalem Bay Health Center and Pharmacy located on the beautiful north Oregon Coast has an immediate job opening for an RN Care Coordinator. This position provides comprehensive care coordination and direct nursing care for our patients in conjunction with the achievement of clinical measures and behavioral health integration. This is a full-time (40 hours per week) position with Medical, Dental, and Vision benefits effective on the first day of employment. Duties: Facilitates communication and coordinates care among patients, family members, healthcare providers and social service agencies to provide patient-centered care, to obtain information, assess the need for appointments and resources; and ensures proper follow up care for post hospital and ED patients. Integrates work with other staff to ensure timely and accurate patient flow. Anticipates clinic and patient needs utilizing nursing judgement. Works with the Director of Quality and the Clinic Manager to achieve clinical measures, utilizing the PDSA methodology. Triages urgent patient telephone calls and walk-ins using nursing assessment skills to determine appropriate level of care needed. Prepares for and leads daily Team-based Care Huddle(s) as part of the Oregon Patient Centered Primary Care Home (PCPCH) model, prompting for gaps in care and appropriate team hand-offs. Understands and addresses social determinants of health, health literacy, and translation services to reduce barriers to patient care. Coordinates care across the healthcare system, taking initiative to connect patients to external resources and follows up to ensure needs have been met. Embraces trauma-informed care and recognizes the value of harm reduction. Identifies other population health needs, performs outreach and coaches patients/families toward successful self-management of chronic diseases or additional primary care health needs. Provides pre-visit planning amongst care team, including advanced visit phone calls, updating the patient’s electronic medical record as appropriate. Provides patients and families with chronic disease education, individually or in a group setting as part of the clinic’s Wellness Program. Documents all encounters in the patient’s medical record. Designs individual treatment plans, recognizing patient identified goals that support each patient’s unique needs. Initiates and documents follow-up for patients, collaborating with the healthcare team and the patient to achieve the best outcomes. Creates a nutritional and physical activity focused dimension to working with patients. Coordinates end of life planning such as hospice and palliative care, POLST completion and provides counseling for patients, families, or caregivers. Assists in identifying and developing clinic workflows and protocols in conjunction with Clinic Manager. Utilizing motivational interviewing, works with patients to create an environment for patient to achieve optimal health. Provides direct nursing care such as wound care, vaccine administration, lab draws, foot care, anticoagulation management and other nursing duties as directed. Maintains patient confidentiality in alignment with HIPAA. Stays current on evidence-based practices, including best practices for the PCPCH model. Attends all appropriate and/or assigned meetings. Complies with clinic’s policies and procedures. Performs other related duties as assigned. Skills/Attributes: Compassionate, sensitive, culturally attuned to the people and community being served and able to communicate effectively. Knowledgeable about the environment and healthcare system. Technically proficient with computers, including electronic health records. Excellent oral and written communication skills. Self-starter who actively contributes to, and strives for, process improvement. Ability to organize and prioritize tasks, works under pressure, and meets deadlines. Strong analytical, attention to detail, and problem-solving skills. Active listener who is interested in being part of a collaborative and patient-centered team. Flexible and willing to adjust to improve the patient and provider experience. Ability to adapt to a fast-paced and sometimes rapidly changing work environment by prioritizing multiple tasks in order to perform efficiently and effectively. Empathy and understanding towards all patients. Recognize, respect, and work effectively with people from diverse social, cultural, and ethnic backgrounds who may have different healthcare preferences and needs. Qualifications: Licensed as a registered nurse in Oregon. Bachelor’s degree preferred. Two years of experience in a community health setting or in a care coordination role preferred. Bilingual preferred (Spanish and English). Must be able to pass national background check and drug screen. Physical Requirements: Ability to communicate both in person and by phone. Ability to lift up to twenty-five (25) pounds. Ability to sit for long periods of time. Ability to walk at a normal pace. Manual dexterity when inputting computer information. Exposure to normal noise, temperature, and dust and fume levels. Job Type: Full-time Benefits: 401(k) 401(k) matching Dental insurance Employee assistance program Employee discount Flexible spending account Health insurance Life insurance Paid time off Relocation assistance Tuition reimbursement Vision insurance Supplemental Pay: Bonus opportunities Overtime pay Ability to Relocate: Wheeler, OR 97147: Relocate before starting work (Required) Work Location: In person