Transition of Care RN
Company: Sea Mar Community Health Centers
Posted on: May 17, 2022
Job DescriptionSea Mar Community Health Centers, a Federally
Qualified Health Center (FQHC) founded in 1978, is a
community-based organization committed to providing quality,
comprehensive health, human, housing, educational and cultural
services to diverse communities, specializing in service to Latinos
in Washington State. Sea Mar proudly serves all persons without
regard to race, ethnicity, immigration status, gender, or sexual
orientation, and regardless of ability to pay for services. Sea
Mar's network of services includes more than 90 medical, dental,
and behavioral health clinics and a wide variety of nutritional,
social, and educational services. We are recruiting for the
following position(s):Sea Mar is a mandatory COVID-19 and flu
vaccine organizationTransition of Care RN - Posting #22993Position
Summary:Join a team that is working hard to provide the best care
possible to our Sea Mar clients who are hospitalized. Will consider
and experienced BA/BS level Care Coordinator and/or LPN for this
position as well. Full-time position available for our Transition
of Care-Care Management Department in Tacoma. The Transitions of
Care RN (TOC RN) delivers specific time-limited services to
identified patients designed to ensure health care continuity,
avoid preventable poor outcomes among at-risk populations, and
promote the safe and timely transfer of patients from one level of
care to another and from one type of setting to another. This
position provides advocacy and education for the patient and/or
caregiver during transitional periods between hospitals and/or
other facilities and the patient's home. The RN collaborates with
staff in hospitals and care facilities and with Sea Mar providers
to resolve gaps in care, improve clinical outcomes related to Plan
all cause readmission, utilization of hospital services, patient
engagement after inpatient discharge and medication reconciliation
post discharge.The Transitions of Care RN provides support with a
focus on the following areas:
- Medication self-management: Patient is knowledgeable about
medications and has a medication management system.
- Patient-centered record: Patient understands and uses a
personal health record to facilitate communication and ensure
continuity of care.
- Primary care and specialist follow up: Patient schedules and
completes follow up visit with the primary care physician and/or
specialist and is prepared to be an active participant in those
- Knowledge of Red Flags: Patient is knowledgeable about
indicators that suggest their condition is worsening and how to
respond.This is a specialized position insofar as the RN or LPN
will have a background working with patients in various settings
(such as with hospice, home health, and acute care hospitals), and
will have an understanding of patients with diverse medical, mental
health, and social determinant of health challenges. Interventions
with patients is time and scope limited, and RNs will not maintain
an ongoing caseload. However, the RNs are expected to complete
outreach and transition of care activities for all patients
identified and willing to participate in the program. Active
participation is expected in community-wide efforts/coalitions to
provide ever-improving comprehensive interdisciplinary care.
Additional responsibilities and information are found on job
description.Education and/or Experience:
- BSN/RN with social service experience: (home health, hospice,
long-term care, case management, care coordination, wellness
- Preferred is an RN but Social Services degree considered.
- CCM or CCTM certification preferred.
- Experience working with underserved, transient populations,
care coordination, case management an chronic diseases.
- Experience working with substance use disorders, chronic mental
illness, and chronic health conditions.
- Experience working with community agencies and has strong
knowledge of community resources.
- Experience with motivational interviewing, the teach-back
method, or patient counseling and education preferred.
- Active RN License with WA State Department of Health.
- Typing proficiency of at least 45 wpm.
- Bilingual (Spanish/English) preferred but not required.What We
Offer:Sea Mar offers talented and motivated people the opportunity
to work in a dynamic and growing community health organization.
Working at Sea Mar Community Health Centers is more than just a
job, it's a fulfilling career with opportunity for advancement. The
fringe benefits surpass most companies. For example, Full-time
employees working 30 hours more, receive an excellent benefit
package of Medical, Dental, Vision, Life Insurance, Prescription
coverage, Long Term Disability, EAP (Employee Assistance Program),
paid-time-off starting at 27 days per year + 10 paid Holidays. We
also offer 401(k)/Retirement options and an exciting opportunity to
work in a culturally diverse environment. How to Apply:To apply for
this position, complete the online application and click SUBMIT or
APPLY NOW. If you have any questions regarding the position, email
Peggy Perry, Program Manager Transitions of Care at
PeggyPerry@seamarchc.orSea Mar is an Equal Opportunity
EmployerPosted 01/11/2022External candidates considered after
01/14/2022This position is represented by Office and Professional
Employees International Union (OPEIU).Powered by
Keywords: Sea Mar Community Health Centers, Tacoma , Transition of Care RN, Healthcare , Tacoma, Washington
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