Transitions of Care Rn

3 weeks ago

Phoenix, United States One Medical Full time

**About Us**

One Medical is a primary care solution challenging the industry status quo by making quality care more affordable, accessible and enjoyable. But this isn't your average doctor's office. We're on a mission to transform healthcare, which means improving the experience for everyone involved - from patients and providers to employers and health networks. Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years.

In February 2023 we marked a milestone when One Medical joined Amazon. Together, we look to deliver exceptional health care to more consumers, employers, care team members, and health networks to achieve better health outcomes. As we continue to grow and seek to impact more lives, we're building a diverse, driven and empathetic team, while working hard to cultivate an environment where everyone can thrive.

**About One Medical - Senior Health**

**_ We are changing healthcare at One Medical Senior Health. How will it change you?_**

On September 1, 2021, One Medical acquired Iora Health, a human-centered primary care organization focused on people 65+ on Medicare. By joining forces, we're able to better address the needs of seniors - an important step in our mission to transform healthcare for all. At One Medical Senior Health, we are transforming health care, starting with primary care. We created a high-impact relationship based care model that particularly benefits adults on Medicare and those who might need more attention. Our care model changes everything - the team, outcome-focused payment, customer service, and the technology that supports our care. We know that when you invest in relationships with people, you can help them live happier and healthier. Our patients get a team that respects and listens to them. We get paid to keep our patients healthier, and it works - we are successfully improving the lives of our patients while lowering costs.

**The Opportunity**

The High Risk Programs is seeking an experienced, full-time Registered Nurse with Care Management or Case Management backgrounds to join the new Transitions of Care team. This is a fully virtual role supporting patients in multiple states/markets. The Transitions of Care RN will support the care of One Medical Senior Health patients discharged from ER visits/stays, acute, and post-acute stays, creating appropriate care plans, and working with internal and external care team members to coordinate care.

**What you'll likely work on**:

- Provide transitional case management to a revolving panel of Senior patients; working with patients, families, providers, and healthcare facilities to improve clinical outcomes and help reduce readmissions to acute care settings.
- Interact with internal and external care team members to provide complex coordination for patients needing short-term case management and safety interventions after discharge from acute care facilities, post-acute care facilities, or emergency departments.
- Serve as the primary liaison between partner providers and the patient's primary care physician (PCP) team during time of transition, engaging in care planning, medication reconciliation, pre
- and post-discharge planning, and facilitating safe handoffs of care.
- Manage assigned patients with the purpose of helping them be more effective at managing their own care, understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately.
- Create a patient centered-care plan with each patient and consistently document planned interventions and patient self-management strategies.
- Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health.
- Communicate significant clinical information regarding assigned patients to other members of the healthcare team and especially to the patient's PCP.
- Attend case conferences and team huddles as appropriate to support and facilitate patient care collaboration
- Effectively navigate health insurance policies and guidelines related to primary care, specialist, acute, rehabilitation and long term care. Develop a positive working relationship with sponsor care management staff.
- Build strong relationships with health systems and facilities, including facilitating coordination and communication channels.

**What you'll need**:

- Licensed Registered Nurse (RN) required and ability to obtain licensure in other states/markets as this fully virtual role and coverage requires.
- 5+ years of RN experience with at least 1 year care coordination/case management experience.
- Demonstrated experience in complex care settings, senior health, or case management experience (preferred), ideally with understanding of home based care services, hospitals/ SNF and long term

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