Transition of Care RN: Posting #19393
Company: Sea Mar Community Health Centers
Location: Olympia
Posted on: February 15, 2021
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Job Description:
Sea Mar Community Health Centers, a Federally Qualified Health
Center (FQHC) founded in 1978, is a community-based organization
committed to providing quality, comprehensive health, human,
housing, educational and cultural services to diverse communities,
specializing in service to Latinos in Washington State. Sea Mar
proudly serves all persons without regard to race, ethnicity,
immigration status, gender, or sexual orientation, and regardless
of ability to pay for services. Sea Mar's network of services
includes more than 90 medical, dental, and behavioral health
clinics and a wide variety of nutritional, social, and educational
services. We are recruiting for the following position(s):Position
Summary:Full-time position available for our Integrated Care-Care
Management Department in Olympia and Lacey. Employee will be
working at both sites. The Transitions of Care RN (TOC RN) delivers
specific time-limited services to identified patients designed to
ensure health care continuity, avoid preventable poor outcomes
among at-risk populations, and promote the safe and timely transfer
of patients from one level of care to another and from one type of
setting to another.This position provides advocacy and education
for the patient and/or caregiver during transitional periods
between hospitals and/or other facilities and the patient's home.
The RN collaborates with staff in hospitals and care facilities and
with Sea Mar providers to resolve gaps in care, improve clinical
outcomes related to Plan all cause readmission, utilization of
hospital services, patient engagement after inpatient discharge and
medication reconciliation post discharge.The Transitions of Care RN
provides support with a focus on the following areas:* Medication
self-management: Patient is knowledgeable about medications and has
a medication management system.* Patient-centered record: Patient
understands and uses a personal health record to facilitate
communication and ensure continuity of care.* Primary care and
specialist follow up: Patient schedules and completes follow up
visit with the primary care physician and/or specialist and is
prepared to be an active participant in those interactions.*
Knowledge of Red Flags: Patient is knowledgeable about indicators
that suggest their condition is worsening and how to respond.This
is a specialized position insofar as the RN will have a background
working with patients in various settings (such as with hospice,
home health, and acute care hospitals), and will have an
understanding of patients with diverse medical, mental health, and
social determinant of health challenges. Interventions with
patients is time and scope limited, and RNs will not maintain an
ongoing caseload. However, the RNs are expected to complete
outreach and transition of care activities for all patients
identified and willing to participate in the program. Active
participation is expected in community-wide efforts/coalitions to
provide ever-improving comprehensive interdisciplinary care.
Additional responsibilities and information are found on job
description.Education and/or Experience:* BSN/RN with social
service experience: (home health, hospice, long-term care, case
management, care coordination, wellness coaching, etc.).* CCM or
CCTM certification preferred.* Experience working with underserved,
transient populations.* Experience working with substance use
disorders, chronic mental illness, and chronic health conditions.*
Experience working with community agencies and has strong knowledge
of community resources.* Experience with motivational interviewing,
the teach-back method, or patient counseling and education
preferred.* Active RN License with WA State Department of Health.*
Typing proficiency of at least 45 wpm. * Bilingual
(Spanish/English) preferred. What we Offer:Sea Mar offers talented
and motivated people the opportunity to work in a dynamic and
growing community health organization. Working at Sea Mar Community
Health Centers is more than just a job, it's a fulfilling career; a
career that allows you to grow in your specialty. Full-time
employees working 30 hours or more, receive an excellent benefit
package; Medical, Dental, Vision, Life Insurance, Prescription
coverage, Long Term Disability, EAP (Employment Assistance
Program), paid-time-off starting at 24-27 days per year + 10 paid
Holidays. Employees also receive 1-2 wage increases per year. We
offer 401(k)/Retirement options and an exciting opportunity to work
in a culturally diverse environment.How to Apply:To apply for this
position, complete the online application and click SUBMIT or APPLY
NOW. If you have any questions regarding the position, email
Susanna Petrie, Program Manager Transitions of Care at
SusannaPetrie@seamarchc.orgSea Mar is an Equal Opportunity
EmployerPosted on 08/01/2019External candidates considered after
08/06/2019This position is represented by Office and Professional
Employees International Union (OPEIU).Powered by
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Keywords: Sea Mar Community Health Centers, Olympia , Transition of Care RN: Posting #19393, Healthcare , Olympia, Washington
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