Transition of Care RN: Posting #19393
Sea Mar Community Health Centers
 Olympia, WA

Sea 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):

Position Summary:

Full-time position available for our Integrated Care-Care Management Department in Olympia and Lacey. Employee will be working at both sites. 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 interactions.
  • 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 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 coaching, etc.).
  • CCM or CCTM certification preferred.
  • Experience working with underserved, transient populations.
  • 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.

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; a career that allows you to grow in your specialty. Full-time employees working 30 hours or more, receive an excellent benefit package; Medical, Dental, Vision, Life Insurance, Prescription coverage, Long Term Disability, EAP (Employment Assistance Program), paid-time-off starting at 24-27 days per year + 10 paid Holidays. Employees also receive 1-2 wage increases per year. We 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 Susanna Petrie, Program Manager Transitions of Care at

Sea Mar is an Equal Opportunity Employer

Posted on 08/01/2019

External candidates considered after 08/06/2019

This position is represented by Office and Professional Employees International Union (OPEIU).