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RN Care Coordinator

Job Purpose:

The priority of this position is to coordinate care for all patients including those diagnosed with opioid use disorder and engaged in medication-assisted treatment, including ongoing assessments, phone intakes, evaluations, triage, teaching, inductions, and stabilization.

Duties:

  • Facilitates communication and coordinates care with community agencies including hospitals, treatment programs, mental health providers and other service providers.  This also includes coordination between patients, family members, healthcare providers, behavioral health providers and social service agencies to obtain information and/or access needed appointments and resources.

  • Acts as primary RN Care Coordinator for the Medication Assisted Treatment (MAT) Program providing ongoing care management, education, and support for patients in all phases of treatment, including: nurse visits, urine toxicology screens, routine labs, medication teaching, monitoring, medication counts and medication refills.

  • Assess and monitor patients in the induction, stabilization, and maintenance phases of treatment.

  • Integrates work with other staff to ensure timely and accurate patient flow before, during and following clinic appointments (e.g., completing SBIRT, Inductions and/or UDS for SUD/MAT patients, behavioral health integration, etc.).

  • Triages urgent patient telephone calls and walk-ins using nursing assessment skills to determine appropriate level of care needed.

  • Addresses social determinants of health, health literacy and translation needs in order to reduce barriers to patient care.  Takes initiative to connect patients to external resources and follows up to ensure needs have been met. 

  • Provides patients and families with education, individually or in a group setting.

  • Embraces trauma-informed care and recognizes the value of harm reduction. 

  • Understands substance use disorder to be a relapsing disease and supports patients during periods of resumed use.

  • Identifies other population health needs, coaching patients/families toward successful self-management of chronic diseases or additional primary care health needs.

  • Documents all engagements in the patient’s medical record.

  • Involves the patient in the treatment plan and works with the patient’s needs.  Initiates and documents follow-up for patients who do not meet their plan of care and/or health improvement goals.

  • Follows up with all patients discharged from emergency departments and hospitals.

  • Maintains patient confidentiality in alignment with HIPAA and 42CFR Part 2.

  • Assists in identifying clinic workflows that create barriers to patient care.

  • Stays current on best practices.

  • Participates in the Clinic’s quality improvement activities with a focus on reaching clinical goals for the population, utilizing the PDSA methodology.

  • Attends all appropriate meetings.

  • Complies with clinic’s policies and procedures.

  • Performs other related duties as assigned.

Skills/Attributes:

  • Compassionate, sensitive, culturally attuned to the people and community being served and able to communicate effectively.

  • Knowledgeable about the environment and healthcare system.

  • Technically proficient with computers, including Microsoft Office Suite.

  • Excellent oral and written communication skills.

  • Ability to organize and prioritize tasks, work under pressure and meet deadlines.

  • Strong analytical, attention to detail, and problem-solving skills.

  • Ability to work independently, and as a team member.

Qualifications:

  • Licensed as a registered nurse in Oregon.

  • Bachelor’s degree preferred.

  • Two years of experience in a community health setting.