The Registered Nurse (RN) is a collaborative member of the care team and provides therapeutic, patient and family centered care utilizing the nursing process. The RN supports three primary nursing areas: care coordination, case management, and telephone triage. Responsibilities include onsite, direct patient care, coordinating care with the patient, the patients’ primary care team, and other healthcare team members, supporting case management activities, and ensuring timely clinical assessments, health education, and appropriate clinical disposition.

Patient Care and Care Coordination

Coordinate the care of complex patients using evidence-based practice. Transitional care management (coordinate ER and hospital follow up as well as care setting transitions). Perform medication reconciliation for moderate/high-risk patients post-discharge from inpatient setting. Develop and manage care plans in collaboration with the primary care providers and other members of the care team. Participate in and/or lead team huddles. In individual or group settings, provide patient and family member education on chronic disease management, acute conditions, and preventive health behaviors. Use motivational interviewing to support health goal setting. Demonstrate proficiency and act as an expert role model in the performance of patient care. Utilize standing orders to manage the care of patients. As a templated provider, see scheduled patients for nurse-led visits, including but not limited to diabetes, hypertension and chronic disease education and management, pregnancy and women’s health-related visits, anticoagulation management, basic wound care. Perform patient outreach and/or follow-up as directed. Provide direct patient care in any clinical role within scope of practice and current competencies, including in-person and telephone triage. Serve as a clinical support resource for Medical Assistant staff and other care team members. Provide in person and/or remote coverage at other clinic sites on an as needed basis; travel within the Mosaic service area. Deliver patient care within HRSA services scope and approved locations, encompassing patient homes, community-based sites, and providing home-based care when necessary and in adherence to defined services and safety protocols. Local travel required. Document all interactions in the EHR in a timely, thorough, and accurate manner. 

Patient Care- Triage

Perform telephone triage and assess patient health condition using the Nursing Process. Effectively utilize decision support tools and approved protocols to provide patient care over the phone. Develop, implement, and evaluate a plan of care for each encounter. Resolve patient issues/concerns and/or route to appropriate staff. Disposition patients to appropriate levels of care. Consult and coordinate with healthcare team members including, but not limited to; primary care providers, nursing, medical assistants, etc. to optimize care. Document all interactions in the EHR in a timely, thorough, and accurate manner. Educate patients about available Mosaic and community resources. Perform emergency department follow-up assessment calls. Receive, review, forward, and/or follow-up on Outside Event notifications. Perform additional patient outreach and/or follow-up calls. Provide patient care in any clinical role within scope of practice and current competencies. Provide on-site coverage at clinics; travel within the Mosaic service area on an as needed basis. Respond to MyChart messages within required timeframe. 

Patient Care and Care Management

Manage a defined panel of high-risk patients with the goals of optimizing the patients’ health status and minimizing inpatient hospital and emergency department utilization. Collaborate with Quality, Value Improvement, and Population Health staff to identify high-risk patients. Implement evidence-based interventions and approved protocols for chronic conditions. Integrate evidence-based clinical guidelines, preventive guidelines, and approved protocols in the development of individualized, patient-centered care plans. Provide follow-up with patients/families regarding transitions of care, including medication reconciliation, timely follow-up appointments, patient education, and coordination of care. Organize and prioritize daily work by assessing new, current, and discharging patient needs in areas of responsibility. Complete documentation as required. Communicate and coordinate with internal and external care teams to ensure quality patient care is received and barriers to care and ongoing care plan are addressed. Assess health, educational, and psychosocial needs of the patient/family and develop, implement and evaluate care plans. Utilize behavioral strategies to provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care. Work closely with the patient’s primary care team to coordinate services and optimize patient care. Utilize available tools to facilitate close monitoring of high-risk patients and/or intervene early during acute exacerbations. Resolve patient issues/concerns and/or route to appropriate staff. Consult with providers as needed Document all interactions in the EHR in a timely, thorough, and accurate manner. Educate patients and families about available Mosaic and community resources. Deliver patient care within HRSA services scope and approved locations, encompassing patient homes, community-based sites, and providing home-based care when necessary and in adherence to defined services and safety protocols. Local travel required.

Work Experience:  Minimum two years of RN clinical experience in acute or ambulatory care required. Care coordination experience in an ambulatory setting preferred. Experience in nurse-led patient visits preferred (i.e. diabetes and chronic disease education, anticoagulation management). In-person and/or Telephone Triage experience preferred. Experience in the care of adult and pediatric populations preferred. 

Education, certification and licensure:  

Required: Associates degree; Current, unrestricted Oregon RN License; BLS/CPR Certification; Valid Oregon State driver’s license Preferred: Bachelor of Science in Nursing (BSN)

Skills & Knowledge:  

Required: Superior nursing process skills. Critical thinking and problem-solving skills. Excellent written, verbal, telephone and interpersonal communication skills. Familiarity/experience with client interaction on the telephone. Knowledge of community resources. Basic typing and computer skills and comfort with Microsoft Windows operating system. Preferred: EHR experience - EPIC experience a plus. Fluency in Spanish preferred. Involvement with quality improvement processes. Knowledge of health insurance plans, standard office policies and procedures as well as regulatory requirements including CLIA and OSHA standards.

Who We are:

Mosaic Community Health prides itself on being an innovative health system that pioneers unique and creative ways to provide and improve patient access to health care. Since our founding in 2002 we have proudly served insured and uninsured patients regardless of age, ethnicity, or income.

We focus on a holistic approach to patient care by incorporating behavioral health, pharmacy, and nutrition support to serve patients in the most meaningful way. At Mosaic Community Health, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team-based environment.

Mosaic Community Health offers more than just a job, it is a lifestyle. A lifestyle of serving others. A lifestyle of being an integral part of your community. A lifestyle that offers work/life balance. A lifestyle of enjoying the outdoors! Central Oregon offers over 300 days of sunshine a year, so enjoy a PTO day on the mountain, biking/hiking trails, or the river! A lifestyle that improves lives, including yours.