### About Us
We are a pioneering primary care solution dedicated to transforming healthcare by making it more accessible, affordable, and enjoyable for everyone. Our comprehensive services effectively integrate both in-office and virtual care, alongside preventive and chronic care management programs. Over the past fifteen years, we've proudly enhanced the healthcare experience for numerous individuals.
In February 2023, we partnered with a renowned organization, positioning us to extend exceptional healthcare services and improve health outcomes for consumers, employers, care team members, and health networks. As we grow, we are committed to building a diverse and compassionate team, creating an environment where everyone can excel.
### The Opportunity
We are looking for an experienced and empathetic Registered Nurse to join our dynamic Transitions of Care team focused on High-Risk Programs. This fully virtual position will support patients across multiple states, including Massachusetts (MA), Georgia (GA), and North Carolina (NC). The role centers around providing essential care to One Medical Senior Health patients during critical transitions, such as discharge from ER visits, acute, and post-acute stays.
### Key Responsibilities
- Provide transitional case management for Senior patients, collaborating with patients, families, providers, and healthcare facilities to improve clinical outcomes and reduce readmissions.
- Work closely with internal and external care teams to ensure complex coordination for patients needing short-term case management and safety support after discharge.
- Serve as a liaison between partner providers and the patient's primary care physician, participating in care planning and medication reconciliation.
- Empower patients with tools and knowledge to manage their health, understand medical conditions, and navigate the healthcare system effectively.
- Create patient-centered care plans and document interventions and self-management strategies consistently.
- Identify and address barriers to care and potential readmission issues related to home health, medical equipment, and social determinants of health.
- Communicate vital clinical information regarding patients to the healthcare team, particularly to the primary care physician.
- Participate in case conferences and team huddles to foster collaboration in patient care.
- Navigate health insurance policies related to a variety of care services efficiently.
### Requirements
- Must hold a Licensed Registered Nurse (RN) designation.
- Based within commuting distance to a One Medical Senior Health office.
- Actively licensed in Massachusetts, with the ability to obtain licensure in Georgia and North Carolina due to the virtual nature of the role.
- A minimum of five years of RN experience, including at least one year in care coordination or case management.
- Experience in complex care settings or senior health is preferred, with knowledge of home-based care, hospitals, and long-term care facilities.
- Strong understanding of utilization management and care management principles.
- Goal-oriented, energetic, and passionate about fostering a positive organizational culture.
- Excellent clinical aptitude, critical thinking abilities, and adaptability in ambiguous situations.
- Proficiency in coaching and teaching techniques, with strong patient-centered communication skills.
- Exceptional interpersonal communication abilities, including listening and writing skills.
- Familiarity with Mac iOS and Google Suite is preferred.
- Spanish proficiency is an advantage.
### Benefits
Taking Care Of You Today
- Paid sabbatical after five and ten years of service.
- Employee Assistance Program with confidential support for team members.
- Competitive medical, dental, and vision plans.
- Free One Medical memberships for you, your friends, and family.
- Pre-tax commuter benefits.
- Option to cash out up to 40 accrued hours of PTO per year.
Protecting Your Future
- 401K matching contributions.
- Credit towards emergency childcare.
- Additional contributions for maternity and paternity leave.
- Paid life insurance.
- Short-term and long-term disability insurance fully covered by One Medical.
### Additional Details
This is a full-time, salaried, remote role that requires proximity to a One Medical Senior Health office and may involve a flexible schedule, including potential weekend work.
We are committed to creating an inclusive workplace and encourage candidates of all backgrounds, abilities, and experiences to explore opportunities with us. One Medical participates in E-Verify and adheres to all relevant employment regulations.
Employment Type: Full-Time