Job Details

Registered Nurse - Trans Care & Outreach

CareOregon, Portland, Oregon

Full Time - Health

Salary Range: DOE

Close Date: 10/09/2020

The Transitional Care and Outreach RN is part of an innovative, community-based team. This position works collaboratively with 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. Using evidence based transitions interventions, the Transitions RN 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 Transitional Care and Outreach Team 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.

Essential Position Functions

The Transitions RN:

  • Provides coordination of care, benefits, community resources and referrals to facilitate safe transitions between care settings
  • 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 of Population Health Partnerships for member resource needs that exceed Oregon Health Plan – Medicaid and/or Centers for Medicare and Medicaid Services – Medicare benefit packages or for situations that appear to warrant medical director assistance or review
Complete details: CareOregon Careers