High Risk RN Care Coordinator

About Us

One Medical is a primary care solution challenging the industry status quo by making quality care more affordable, accessible and enjoyable. But this isn’t your average doctor’s office. We’re on a mission to transform healthcare, which means improving the experience for everyone involved - from patients and providers to employers and health networks. Our seamless in-office and 24/7 virtual care services, on-site labs, and programs for preventive care, chronic care management, common illnesses and mental health concerns have been delighting people for the past fifteen years.

In February 2023 we marked a milestone when One Medical joined Amazon. Together, we look to deliver exceptional health care to more consumers, employers, care team members, and health networks to achieve better health outcomes. As we continue to grow and seek to impact more lives, we’re building a diverse, driven and empathetic team, while working hard to cultivate an environment where everyone can thrive.

The Opportunity

The One Medical at Home (OM@H) Program is seeking an experienced, Remote, full-time Registered Nurse with a Care Management or Case Management background to join our team. This is a fully virtual role supporting patients in multiple states/markets. The OM@H RN will support the care of One Medical Senior Health patients enrolled in the OM@H program by working with internal and external care team members to coordinate patient care.

The OM@H RN will create appropriate action plans, triage patient phone calls, and manage transitions of care to acute and post acute facilities.

The ideal candidate is goal oriented, uses critical thinking and creativity to address challenges, and is comfortable with ambiguity. You are skilled in chronic disease education and care management, and passionate about Seniors’ health and demonstrate outstanding clinical aptitude and judgment when caring for a patient.

Employment type:

• Full time
• 40 hours per week
• Must be able to work Monday through Friday, 8AM - 5PM in Pacific Time Zone

What you’ll be working on:

• Participate in daily huddles and weekly rounding with your assigned market care teams to review overnight calls, previous day triages, complex patient care needs, new facility admissions, pending facility discharges, and provider daily schedules
• Address tasks assigned to you by various team members for your patient panel including, but not limited to, lab results, medication questions, short term education needs, action plan requests, and triage follow up
• Work together with other RNs to respond to incoming patient calls across all markets that require nursing triage
• Respond timely to multiple Slack channels where team members post urgent needs throughout the day
• Serve as the primary liaison between partner providers and the patient’s primary care provider (PCP) team during time of transition, engaging in action planning, medication reconciliation, pre- and post-discharge planning, and facilitating safe handoffs of care
• Manage assigned patients with the purpose of helping them be more effective at managing their own care, understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately
• Create a patient centered-action plan with each patient and consistently document planned interventions and patient self-management strategies
• Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health
• Communicate significant clinical information regarding assigned patients to other members of the healthcare team and especially to the patient’s PCP
• Attend care coordination rounds and team huddles to support and facilitate patient care collaboration
• Effectively navigate health insurance policies and guidelines related to primary care, specialist, acute, rehabilitation and long term care
• Develop a positive working relationship with sponsor care management staff
• Build strong relationships with health systems and facilities, including facilitating coordination and communication channels

Education, licenses, and experiences required for this role:

• AZ…