Clinical Lead Comprehensive Care Program

Martins Point Health Care   •  

Portland, ME

Industry: Healthcare IT


8 - 10 years

Posted 376 days ago

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond.  As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community.  Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day.  Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.


Position Summary

Martin’s Point Health Care is partnering with Health Quality Partners to to deliver advanced, community-based preventive care and care management interventions for chronically ill older adults. The HQP model of care focuses on the following:
• Management/prevention of the onset or complications from common chronic diseases - heart failure, coronary artery disease, chronic lung disease, depression, and diabetes
• Avoiding complications and preventing hospitalizations associated with chronic conditions and aging
• Promoting safety and independence and optimizing physical and social functioning
• Assisting with and facilitate long term advanced care planning

The Clinical Lead Comprehensive Care Program provides leadership and mentorship to the Community Care Nurses and Comprehensive Care Program team to ensure reliable, high quality, person centered delivery of HQP’s care model/s for patients, families and health care providers.

In collaboration with Comprehensive Care Program leadership, recruits, screens and interviews well qualified nurses for new, innovative and pioneering nursing roles that will improve patients’ health outcomes and patient/family and provider experience.

Demonstrates expertise in practice, and in orienting, training, teaching and developing nurses to conduct comprehensive and multi-dimensional patient assessments and proactive patient management aimed at anticipating problems, avoiding complication, mitigating risks, preventing injuries, and reducing unnecessary hospital admissions and emergency department visits.

Mentors and supports nurses toward role effectiveness, utilizing SPERO, policies, procedures, protocols, national guidelines, standards of care, other clinical resources, HQP data analysis and reports.  Employ techniques such as observation, role play, counseling, coaching and discipline, as needed, to achieve high performance and reliability in the delivery of care management. Serve as a primary clinical support to nurses for patient related issues, questions, concerns.

Collaborates with Comprehensive Care Program leadership to develop, implement and manage new programs, interventions, services; including, but not limited to care models and interventions that meet the needs of the patient populations served, policies, procedures, processes, protocols, standards, reports (patient, nurse, management level), and decision support tools. Assure high reliability in delivering program interventions that achieve intended aims and meet the needs of the populations.

Conducts initial patient outreach and consent visits, determine timing for next visit. Manages a patient caseload and provide back up and overflow support as a primary care manager according to organizational needs.

Demonstrates leadership to achieve MPHC strategic aims, program goals, and objectives.

Demonstrates excellence in communication, flexibility and adaptability, superior problem solving skills, accessibility and responsiveness to MPHC leadership and staff. Strives to incorporate the principles of high reliability in practice and teach and mentorothers the same.

Job Description

Company: Martin’s Point Health Care ( in collaboration with Health Quality Partners (

Location: Greater Portland area


  • RNrequired (BSN or MSN preferred)
  • Ten years of recent and progressive experience in nursing or health care field with current clinical experience.
  • Evidence of superior and proven leadership and management skills
  • Basic Life Support (BLS) certification is required

Required License(s) and/or Certification(s):

  • Unrestricted state registered nurse license required: BSRN or MSRNpreferred
  • Valid unrestricted driver’s license

Skills/Knowledge/Competencies (Behaviors):

  • Demonstrates an understanding of and alignment with Martin’s Point Values.
  • Clinical knowledge and experience in geriatrics, community based nursing and care management, lifestyle and behavior change theory, disease management, evidence based care and guidelines.
  • Experience in program development, implementation and staff management.
  • Advance collaboration skills in working with patients, families, physicians, etc.
  • Experience and enthusiasm for learning principles of continuous quality improvement (e.g PDSA, Six Sigma, statistical process control methodologies and high reliability).

Do you have a question about careers at Martin’s Point Health Care? Contact us at: