Transitional Care Management RN

PORTLAND CLINIC • Beaverton, OR

100d

About The Position

At The Portland Clinic our mission is to be a trusted community collaborating to improve the health and well-being of those we serve. Join our team and let us work together to offer a welcoming, inclusive environment for our patients and the communities we serve. The Transitional Care Management (TCM) RN will work collaboratively with patients, physicians, staff, and other health care professionals in overseeing the care of a patient as they move from one health care facility, such as a hospital or a Skilled Nursing Facility (SNF), to another facility or their home. The TCM nurse oversees the management of patients in the 30 day period post-discharge, assists with teaching patients how to self-manage their chronic conditions, and provides triage and nursing advice in person, via telephone and through electronic messaging. The goal of the Transitional Care Management program is to reduce disruptions in care, and lower the chances of patients readmitting to the hospital.

Requirements

• RN graduate of an accredited School of Nursing
• Valid Oregon Nursing License
• BLS certification

Nice To Haves

• 2+ years of previous hospital or ambulatory/clinic nursing experience strongly preferred.
• Basic understanding of medical terminology
• Ability to make complex healthcare decisions
• Ability to respond quickly and calmly in difficult situations
• Knowledge of charting and telephone legalities
• Possess compassion and the ability to work with others in a team-based setting
• Strong patient assessment ability
• Keyboarding skills
• Basic computer skills
• Competency in language, grammar and spelling
• Oral communication skills and excellent phone etiquette with the ability to convey and receive information via the telephone
• Capability of effectively working on more than one task without a reduction in the quality of work and service performed

Responsibilities

• Work collaboratively with the care team to manage the TCM process for patients discharging from the hospital or SNF and support the TCM providers and PCPs in safely transitioning patients from the inpatient to the community setting.
• Work closely with TCM providers to provide holistic, comprehensive care to TCM patients; participate in program development and growth, in partnership with the Population Health Manager.
• Serve as a super user for PointClickCare.
• Perform medication reconciliation on patients after a transition of care.
• Facilitate referrals to care management for patients needing ongoing support post TCM period; partner with care management team for patients currently enrolled in care management.
• Maintain current knowledge of community resources to support patients.
• Arrange post-discharge medical and community referrals for patients with health problems requiring further evaluation and/or additional services.
• Serve as an advocate for patients and families.
• Follow The Portland Clinic’s (TPC) guidelines for documentation in the electronic health record.
• Counsel and educate patients regarding issues such as wound or injury care, diabetic teaching, symptom monitoring, emotional concerns and self-management of disease.
• Manage inbasket work and provide triage support for patients enrolled in the TCM program.
• Assist with protocol-driven medication refills.
• Perform assessments based on patient need for appointments, advice or other treatment according to clinical knowledge, written protocols and standing orders. Report to clinician, document and schedule as needed. Maintain current knowledge regarding clinic-approved telephone nursing protocols.
• Comply with TPC, HIPAA and OSHA guidelines at all times to ensure patient and staff safety.
• Maintain an active BLS certification.
• Attend nursing meetings and in-services virtually and in person.
• Participate in other relevant committees and meetings as directed.
• Serve as an integral member of the care team.
• Provide assistance and training to other staff, as needed.
• Assist other departments as needed.
• Work respectfully and collaboratively with a spirit of cooperation.
• Participate as an active care team member in a patient-centered medical home.
• Maintain regular work attendance and punctuality.
• Other duties, as assigned.

Benefits

• 401k plan with Employer Matching up to 4.5% annually
• Roth IRA
• Comprehensive Medical, Dental and Vision insurance
• Flexible Spending Account
• Health Savings Account
• Company provided $10K Group Life/AD&D insurance
• Voluntary benefits: Life/AD&D, Dependent Life/AD&D, Short-Term Disability, Critical Illness, Accident, and Hospital Indemnity
• Norton Identity Theft Protection (optional)
• Pet Insurance (optional)
• 4.92 hours of PTO accrual per pay period (PTO accrual is prorated based upon FTE)
• One paid Wellness day per year
• Seven paid holidays, and 1 partially paid holiday (mid-day closure)
• Employee Assistant Program

What This Job Offers

• Job Type: Full-time
• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees