We are a pioneering primary care solution dedicated to revolutionizing healthcare, making it more accessible, affordable, and enjoyable for all. With a commitment to transforming the industry, our comprehensive services seamlessly blend in-office and virtual care, alongside preventive and chronic care management programs. Over the past fifteen years, we've delighted countless individuals with our innovative approach to healthcare.
In February 2023, we achieved a significant milestone by joining forces with a renowned partner. Together, we're poised to deliver exceptional healthcare to a broader audience, driving better health outcomes for consumers, employers, care team members, and health networks. As we continue to expand and impact more lives, we're focused on fostering a diverse, driven, and empathetic team within an environment where everyone can thrive.
The Opportunity
We are seeking an experienced and compassionate full-time Registered Nurse to join our dynamic Transitions of Care team within the High Risk Programs. This fully virtual role supports patients across multiple states/markets (MA, GA, and NC) and focuses on providing essential care to One Medical Senior Health patients during critical transitions, including discharge from ER visits/stays, acute, and post-acute stays. As a Transitions of Care RN, you will play a pivotal role in creating personalized care plans and collaborating with internal and external care team members to ensure seamless coordination of care.
Key Responsibilities
Provide transitional case management for a diverse panel of Senior patients, working closely with patients, families, providers, and healthcare facilities to enhance clinical outcomes and minimize readmissions.
Collaborate with internal and external care team members to facilitate complex coordination for patients requiring short-term case management and safety interventions post-discharge.
Act as the primary liaison between partner providers and the patient's primary care physician (PCP) team, engaging in care planning, medication reconciliation, and facilitating safe transitions of care.
Empower patients to effectively manage their own care, understand medical conditions and medications, navigate the healthcare system, and utilize resources appropriately.
Develop patient-centered care plans and document planned interventions and patient self-management strategies consistently.
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, especially the patient's PCP.
Attend case conferences and team huddles to support and facilitate patient care collaboration.
Navigate health insurance policies and guidelines related to primary care, specialist care, acute, rehabilitation, and long-term care effectively.
Requirements
Licensed Registered Nurse (RN) required.
Must be based within commuting distance to a One Medical Senior Health office.
Actively licensed in the state of Massachusetts and able to obtain licensure in other states/markets (GA/NC) due to the fully virtual nature of the role.
5+ years of RN experience, including at least 1 year of care coordination/case management experience.
Demonstrated experience in complex care settings, senior health, or case management (preferred), with an understanding of home-based care services, hospitals/SNFs, and long-term care facilities.
Advanced knowledge of utilization management/care management principles.
Goal-oriented, high-energy individual with a passion for organizational values and fostering a positive work culture.
Outstanding clinical aptitude, critical thinking skills, and ability to operate effectively in ambiguous situations.
Proficient in core coaching and teaching techniques, including motivational interviewing and patient-centered communication.
Excellent interpersonal communication skills, including exceptional listening skills and demonstrated writing skills.
Familiarity with Mac iOS, Google suite preferred.
Spanish proficiency is preferred.
Benefits
Taking care of you today:
Paid sabbatical after 5 and 10 years.
Employee Assistance Program - Free confidential advice for team members.
Competitive Medical, Dental, and Vision plans.
Free One Medical memberships for yourself, friends, and family.
Pre-Tax commuter benefits.
PTO cash outs - Option to cash out up to 40 accrued hours per year.
Protecting Your Future For You And Your Family
401K match.
Credit towards emergency childcare.
Extra contributions toward maternity and paternity leave.
Paid Life Insurance.
Disability insurance - One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance.
Additional Details
This is a salaried, full-time, remote role requiring proximity to a One Medical Senior Health office.
The role may involve a varied schedule, including the possibility of compressed schedules and alternating weekends.
We are committed to fostering an inclusive workplace and encourage qualified applicants of every background, ability, and life experience to explore opportunities with us. One Medical participates in E-Verify and complies with all relevant employment regulations.
Please refer to the E-Verification Poster (English/Spanish) and Right to Work Poster (English/Spanish) for additional information.
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Other
Industries
Human Resources Services
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