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WorkSource Oregon RN Care Coordinator in Bend, Oregon

Mosaic Medical prides itself on being an innovative community health center system that pioneers unique and creative ways to provide 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 Medical, you will work with incredibly dedicated and mission-centered peers and be part of a dynamic team based environment. Our organization maintains a HPSA rating of 17 and qualifies for NURSE Corp, a Loan Repayment Program. Mosaic Medical 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. Of course, we also offer a great benefit package! This position is also eligible for loan repayment through NURSE Corp. Opportunity The RN Care Coordinator functions as the clinic care team RN, and provides support to patients and care plan management utilizing the nursing process. The goal is to provide individualized education, coaching and follow-up to improve patients' self-management skills. Interventions are intended to help patients and patient populations adhere to treatments and maintain their quality of life with chronic diseases and/or complex illnesses. The RN Care Coordinator provides direct patient care and also facilitates the coordination of care between others involved in the care of the patient, including the patient's primary care team, medical specialists, hospitals, and health plans. Responsibilities -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 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