High Risk Care Manager RN

• The Opportunity:

  One Medical is looking for RNs with care/case management backgrounds to join our rapidly growing Senior Health Care Team. In this hybrid remote and in-office role, you will support and follow complex One Medical Senior patients as they transition across the care continuum.

  What you'll likely work on:

  • Provide care management to a panel of 100-150 complex patients by working with patients, families, providers, and healthcare facilities to improve clinical outcomes and help reduce admissions and emergency department visits
  • Interact with internal and external care team members to provide coordination for patients who are at high risk of admission or were recently discharged from acute care, post-acute care, or emergency departments
  • Serve as the primary liaison between the patient, partner providers and the patient’s primary care team during time of transition, engaging in care planning, medication reconciliation, pre- and post-discharge planning, and safe handoffs of care
  • Support patients with the purpose of helping them be more effective at managing their own care, navigating the healthcare system, and understanding their medical conditions and medications
  • Create a patient centered-care plan for each patient in partnership with the Senior Health Medical Director, and document planned interventions and patient self-management strategies
  • Collaborate with primary care providers to join select office appointments for high risk patients
  • Address and resolve post-discharge barriers and potential readmission factors including home health, durable medical equipment, and social determinants of health
  • Attend case conferences and team huddles to support collaborative patient care
  • Navigate health insurance policies regarding acute and long term care
  • Collaborate with and provide clinical support for Health Navigators
  • Build strong relationships with health systems and facilities, including facilitating coordination and communication channels

  What you'll need:

  • 2+ years of nursing experience in hospital, post-acute facility, or ambulatory setting 
  • RN license in CA required, with a willingness to obtain licenses in other states 
  • Ability to work 8am-5pm Pacific Time; working at least two days per week in-office with primary care providers and health navigators
  • Knowledge of the greater Bay Area healthcare landscape and geography or willingness to rapidly learn
  • Knowledge of utilization management/ care management principles
  • Experience in one or more the following: care management, value-based care, care coordination, virtual care (preferred)

This is a full-time hybrid remote role, based 2+ days per week in our Redwood City office.

Benefits designed to aid your health and wellness:

Taking care of you today

• Paid sabbatical after 5 and 10 years
• Employee Assistance Program - Free confidential advice for team members who need help with stress, anxiety, financial planning, and legal issues
• Competitive Medical, Dental and Vision plans
• Free One Medical memberships for yourself, your friends and family
• Pre-Tax commuter benefits
• PTO cash outs - Option to cash out up to 40 accrued hours per year

Protecting your future for you and your family

• 401K match
• Credit towards emergency childcare
• Company paid maternity and paternity leave
• Paid Life Insurance - One Medical pays 100% of the cost of Basic Life Insurance
• Disability insurance - One Medical pays 100% of the cost of Short Term and Long Term Disability Insurance