PATHS-CC Nurse Care Manager

Department Overview

The Oregon Health & Science University (OHSU) Division of Geriatrics and Internal Medicine is seeking a clinically licensed, mid-level Mental Health Provider (MHP) to join a dynamic, multidisciplinary team of clinicians and researchers as part of the PATHS-CC initiative (Peer-Assisted Telemedicine for Health in Substance Users–Comprehensive Care).

 

PATHS-CC is an innovative telemedicine-based program designed to provide on-demand behavioral health and substance use care to people who use drugs across Oregon. The program prioritizes individuals experiencing homelessness, serious mental illness (SMI), co-occurring disorders (COD), and hepatitis C (HCV)—populations often underserved in traditional care models.

 

This initiative integrates same-day HIV/HCV testing and diagnosis with immediate access to behavioral health services and aims to improve outcomes in high-need communities while developing scalable models for HCV elimination.

 

The Nurse Care Manager (RN) serves as the primary clinical liaison between clients, Peers, and healthcare providers within the PATHS-CC program. As a licensed Registered Nurse, the RN Care Manager is responsible for conducting telemedicine-based clinical screenings, coordinating care, triaging clients to appropriate same-day telemedicine visits, and managing follow-up activities to ensure timely and effective treatment across a range of conditions.

 

The RN works closely with Site Peer Coordinators and Peers to support clients through case management, facilitated referrals, and system navigation.

Function/Duties of Position

• Overall coordination of the clinical responsibilities of the program, ensuring client-centered, timely coordinated care serving as a bridge between community-based outreach and medical treatment services.
• Screening participants for serious mental illness (SMI), co-occurring disorders (COD), substance use disorders (SUD), and suicidal ideation
• Managing lab results and coordinating follow-up care for HCV, HIV, hepatitis B, and hepatic fibrosis, including initiating follow-up labs and arranging telemedicine appointments with HCV/HIV providers.
• Discussing PrEP and ordering baseline labs, facilitating on-demand visits for PrEP and PEP initiation as clinically indicated.
• Coordinating referrals for STI screening, SUD medications, intensive outpatient programs, and ongoing hepatitis B management based on clinical protocols.

Required Qualifications

• BSN and 5 years of related experience in an RN role, or BSN and relevant Master’s degree plus 3 years of related experience in an RN role.
• Current OR RN licensure and BLS certification required at time of hire.
• Prior experience with telemedicine, case management, or community-based care
• Three (3) years of clinical nursing experience
• Experience in providing integrative care with a track record of working with teams of health care providers and support staff from different disciplines.
• Experience in nurse management.
• Strong triage and clinical decision-making skills, with the ability to work independently under delegated protocols.
• Ability to process and handle confidential information with discretion
• Ability to adapt to change quickly and positively
• Ability to lead and facilitate effective teams
• Ability to support multiple initiatives and balance priorities
• Detail-oriented
• Excellent written and verbal communication skills
• Superior organization and time management skills
• Self-motivated and able to work autonomously
• Strong project management and critical thinking/analytical skills
• Proficiency in Microsoft Office applications
• Interest in conducting research consistent with the complexity of issues that arise in primary care and the delivery of integrated care

Preferred Qualifications

• Certification in telehealth or care management (preferred but not required) preferably in behavioral health, substance use treatment, infectious disease (HCV/HIV), or care coordination.

Additional Details

• This is a 1.0 FTE position with a daytime schedule and may include weekend or evening hours. This position will be a remote.  
• Must be able to sit or stand for the duration of the shift.
• Ability to do phone or computer work for the duration of the shift.
• Must be able to stay alert for long stretches of time.
• Significant use of computers, copiers, multi-line phones, and fax. 
• Must be able to deal with competing needs and priorities of internal and external customers.

All are welcome

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