RN Care Coordinator

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 Us

One Medical Seniors is a network of primary care practices where we take the time to know our patients as true individuals, and proactively provide the care, support, and inspiration they need to live their best life. 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. Our practices offer smaller panel sizes, no billing or coding, and the opportunity to lead systemic change in health care delivery while working with a true team. One Medical Seniors wants to restore humanity to healthcare, for both patients and team members. 

The Opportunity  

We are seeking a full time Registered Nurse experienced in complex care / case management to join our One Medical at Home program within the High Risk Care Programs. This is a virtual/remote role and serves patients within multiple states/ markets (CO [primary], AZ, GA, TX, WA). Candidates should live within a commuting distance of the OM@H service areas as well as the Senior Health practices.

The High Risk Care Coordinator will serve as a key member of the One Medical at Home team, playing a critical role with other members of the clinical team (providers, health coaches, Social Workers, Behavioral Health Specialists) to provide accessible, comprehensive, coordinated care based on longitudinal healing relationships. The Nurse's primary responsibilities center around the delivery of clinical nursing care, patient education, and achieving continuous excellence, through partnering with high risk/ complex care patients, their caregivers, and varied healthcare providers in managing chronic conditions and care transitions. 

What You Will Work On

• Longitudinal Complex Care Management: 
• Establish effective virtual, clinically engaged relationships, to proactively manage a panel of 150-300 patients with complex, chronic medical conditions to monitor for self-management, reinforce disease management, and identify early need for appropriate clinical intervention. 
• Use patient centered communication skills and health behavior change strategies (e.g. Motivational Interviewing; action plans/SMART goals) to support patients and reduce the need for emergency care or acute care admissions
• Create patient-centered care plans and ensure all identified High Risk Patients have accurate and up-to-date nursing care plans, with clear next steps/follow-up outlined.
• Through teaching, coaching and engagement, increase patient’s self-efficacy, including understanding of their conditions, treatment adherence, and basic chronic disease.
• Serve as the primary liaison between partner providers and the patients’ primary care physician (PCP) team during times of transition, engaging in care planning, medication reconciliation, pre- and post-discharge planning, and facilitating safe handoffs of care.

• Triage: 
• Serve as the primary point of contact for patients seeking clinical support to help the High Risk Care Team determine next best steps to evaluate and treat the patients presenting concerns. The RN demonstrates an ability to recognize health conditions requiring urgent intervention and comfort with communicating urgent needs to key team members. 
• Possess excellent problem solving skills and an ability to overcome systematic hurdles in order to fulfill patient needs.
• Help to create and adjust daily schedule for High Risk Care Team based on patient clinical needs.  

• Complex Case Management/  Transitions of Care: 
• Collaborate with key external staf