Thank you for your interest in career opportunities at Central City Concern!

Since 1979, the Portland Community has trusted Central City Concern (CCC) to help people create meaningful, long-term change. Every year, we serve more than 13,000 people experiencing, or at risk-of, homelessness with affordable and supportive housing, person-centered health care, addiction recovery and employment assistance. By providing health care, housing and jobs, CCC is ending homelessness in Portland and helping people achieve their highest potential. 

 

Now Hiring: Join Central City Concern's groundbreaking Recuperative Care Program as a RN Complex Care Manager

Location: Central City Concern - Evergreen Crossing Primary Care Center (8225 NE Wasco Street, Suite 300, Portland, 97220)

***Schedule: 

Summary:

The RCP RN Complex Care Manager works as a medical leader for the Recuperative Care Program, a medical respite facility operating in alignment with Central City Concern primary care services and serving adults with medical needs and experiencing houselessness. The Recuperative Care Program (RCP) provides emergency housing, access to medical support, and intensive case management for participants who have acute, sub-acute, and chronic health conditions. RCP provides non-judgmental support for participants with substance use disorders and mental health needs.

The RCP RN position develops, manages, and utilizes systems for assessment of referrals into the service, including protocols for gauging suitability for patient enrollment, tracking of participant’s medical status through their enrollment, and completion of medical goal in alignment with participant discharge. 

This position provides complex care coordination for a subset of medically complex clients receiving RCP services, provides health education to clients as appropriate, and consultative support providing medical expertise to the non-clinical RCP staff. This role requires a strong foundation of understanding the causes of homelessness and poverty, the medical and psychosocial sequelae of homelessness and the systems and processes used to help complex and medically vulnerable participants secure and maintain stable housing, healthcare, and other social services.

The Complex Care Manager, RN role uses a trauma-informed, participant-centered lens in the augmentation of support within RCP’s care coordination structure, acts as a primary point of contact for complex care coordination needs with community partners, and serves as a program development catalyst, working with CCC leadership on population health, data analysis, patient safety and quality improvement initiatives.  

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Lead RCP medical decision-making in concert with RCP Medical Director.
2. Direct RCP patient care initiatives appropriate to RCP’s care setting and in alignment with primary care resources.
3. Carry out infection prevention and outbreak mitigation measures for RCP’s congregate setting in concert with department of public health guidance.
4. Lead and support population health, data analysis, and quality improvement initiatives in collaboration with CCC leadership.
5. Develop, manage, and utilize systems for assessment of referrals into the service.
6. Track RCP participant’s medical status through their enrollment and make determinations regarding participant’s medical stability to determine appropriateness of discharge.
7. Work as a member of the Recuperative Care Program multi-disciplinary team to deliver comprehensive, client centered and trauma informed integrated services.
8. Provide clinical oversight to RCP participant care plans.
9. Supervise nursing students as applicable.
10. Provide on-call supervisorial support to non-clinical RCP staff as appropriate.
11. Actively participate in the integration of services at the Evergreen Crossing Primary care clinic and identify new opportunities to improve collaboration between and within service and care teams while carefully following information-sharing guidelines.
12. Proactively identify opportunities for improvement within Recuperative Care Program workflows and logistics. Participate in review of RCP Key Performance Indicators; review and contribute to continuous improvement opportunities and plans.
13. Build understanding of and appreciation for diversity among Recuperative Care Program clients and support their connection to culturally responsive and culturally specific services as requested.
14. Complete clinical assessments to determine program eligibility for referred participants.
15. Provide RCP staff education and support around basic medical knowledge.
16. Proactively communicate with enrolled participants’ Primary Care Providers and clinical teams, working to ensure early post-hospital contact and ongoing appointments as appropriate.
17. Develop relationships and workflows with external primary care clinics to increase understanding of RCP model and maximize PCP engagement during participants’ respite care stay.
18. Collaborate with multidisciplinary team on development of medical respite care plans.
19. Provide participant education and health coaching on topics including diabetes, hypertension, and other chronic diseases, and including assisting participants with self-management goal-setting.
20. Provide regular triage for participants experiencing acute and sub-acute illnesses for the purpose of coordinating care.
21. Provide non-invasive medical treatments, including taking vital signs, performing limited wound dressings, etc.
22. Provide wound care at Evergreen Crossing Primary care on an as-needed basis
23. Provide medication monitoring, in partnership with Blackburn pharmacy, in accordance with participant’s care plan.
24. Evaluate enrolled participants for medical stability, collaborating with the participants’ primary care providers.
25. Participate in and facilitate collaborative multi-disciplinary care coordination, including case conferences and care coordination huddles.
26. Participate in population health activities, including participant chart and ALERT system reviews to ensure that participants have received appropriate vaccination for influenza and pneumonia.
27. Develop and maintain standardized protocols and programmatic interventions based on most common diagnoses of enrolled participants, in collaboration with participants and relevant care providers.
28. Support community partners in furthering understanding of the medical and psychosocial impacts of homelessness and the systems and processes used to help complex and medically vulnerable participants secure and maintain stable housing, healthcare, and other social services.
29. Update and appropriately document in participant records in a timely manner with participant interactions, appointments, and encounters.
30. Participate in admission and discharge planning for any participant needing hospitalization or sub-acute level of care.
31. Adhere to all state and federal privacy regulations, including HIPAA and 42 CFR Part 2, and to CCC policies and agreements regarding confidentiality, privacy, and security. Support compliance with all privacy and security requirements pursuant to community partners’ and outside providers’ patient confidentiality agreements, including privacy and security requirements for EMR access.  This includes immediately reporting any breach of protected health information or personal identification information of any person receiving CCC services by CCC or an outside provider to the CCC Compliance Department, as well as to your supervisor or their designee.
32. Attend all mandatory CCC trainings in a timely manner.
33. Perform other duties as assigned.

Skills and Abilities:

1. Ability to consider the impacts and outcomes for underserved communities during decision-making processes.
2. Ability to consider impacts of systems of oppression, structural racism, and individual bias on client outcomes.
3. Demonstrated ability to adhere to trauma-informed care principles.
4. Ability to exhibit good nursing judgment in the care of complex participants and knowledge of nursing theory and practice.
5. Ability to triage complex medical patients to higher levels of care
6. Ability to identify patients who are at risk of medical decompensation and takes steps to mitigate decompensation
7. Ability to communicate effectively to nurses and doctors across health care system to advocate for patients
8. Working knowledge of principles, practices and procedures of outpatient care and programs and services available to participants.
9. Ability to be flexible and to coordinate and relate effectively with members of several interdisciplinary teams, participants, supervisors and co-workers.
10. Ability to update and appropriately document in participant records in a timely manner with participant interactions, appointments, and encounters.
11. Ability to develop and maintain positive working relationships with and effectively communicate with the general public, participants, medical personnel, corrections personnel, police, and co-workers.
12. Ability to participate in Quality Improvement initiatives, anchoring a medical stake in clinical QI processes.
13. Ability to create and administer trainings to non-medical team members
14. Sufficient manual dexterity and physical ability to perform assigned tasks including simple wound care procedures or similar tasks.
15. Follow policies and procedures of the Recuperative Care Program and Central City Concern
16. Ability to apply knowledge of nutrition, sanitation, and personal hygiene.
17. Ability to be flexible and manage time, deadlines and multiple priorities.
18. Demonstrated ability to relate to individuals and families of varied ethnic, cultural and socioeconomic backgrounds, ages and living circumstances.
19. Ability to maintain accurate records and necessary paperwork.
20. Ability to maintain strict standards of confidentiality with regard to patient information.
21. Ability to maintain a calm professional demeanor and make independent judgments.
22. Ability to transport participants in company vehicle.

MINIMUM QUALIFICATIONS (REQUIRED)

1. Required: Successful completion of a course of accredited study that leads to the AD, or BS or AA degree in Nursing from OSBN or State Board approved course.
2. Required: Current RN license in the State of Oregon.

PREFERRED QUALIFICATIONS

1. Preferred: At least three years of experience working in a pre-hospital or post-hospital setting with demonstrated medical care coordination.
2. Preferred: Bilingual.

ADDITIONAL CONSIDERATIONS

1. Must have ability to exhibit good nursing judgment in the care of complex participants and knowledge of nursing theory and practice.
2. Must have ability to triage complex medical patients to higher levels of care
3. Must have ability to identify patients who are at risk of medical decompensation and takes steps to mitigate decompensation.
4. Must have the ability to provide clinical oversight to RCP care plans.
5. Must have ability to communicate effectively to nurses and doctors across health care system to advocate for patients.
6. Must meet CCC privileging requirements as required by FTCA.
7. Must understand the causes of homelessness and poverty, the medical and psychosocial impacts of homelessness and the systems and processes used to help complex and medically vulnerable participants secure and maintain stable housing, healthcare, and other social services.
8. Must have experience working with high-risk participants.
9. Must have a high tolerance for ambiguity and change.
10. Must be able to document nursing interventions and responses to care and do so in an accurate, legible, and intelligible manner.
11. Must have excellent reading and comprehension skills.
12. Ability to adhere to Central City Concern’s drug-free workplace which encourages a safe, healthy and productive work environment and strictly complies with the Drug-Free Workplace Act of 1988. An employee shall not, in the workplace, unlawfully manufacture, distribute, dispense, possess or use a controlled substance or alcohol.
13. Current CPR certification required prior to start.
14. Must possess a current driver’s license and qualify as an Acceptable Driver as designated in Central City Concern’s Fleet Safety policy.  Must pass an initial drivers training within 60 days of being an approved driver and continued recertification training.  Must maintain vehicle insurance coverage of a minimum of $100,000/$300,000 personal auto liability coverage.

BENEFITS at CCC

Central City Concern offers incredible benefits to our employees. We offer an extensive total rewards package to include base wages, medical, dental, vision and voluntary plans. Central City Concern also takes employees’ financial wellness into consideration and provides a rich retirement match. In the spirit of inclusivity, we celebrate 11 holidays and have a generous paid time off (PTO) plan.

• Generous paid time off plan beginning at 4 weeks (of accrued time) per year at the time of hire. Accrual increases with longevity.  
• Amazing 403(b) Retirement Savings plan with an employer match of 4.25% in your 1st year, 6% in the 2nd year, and 8% in your 3rd year! 
• 11 paid Holidays + 2 Personal Holidays to be used at the employee’s discretion. 
• Comprehensive Medical, Vision, and Dental insurance coverage. 
• Employer Paid Life, Short Term Disability, AND Long-Term Disability Insurance! 
• Sabbatical Program offering extended time off at years 7, 14, and 21.