Complex Care Nurse

Harbor Health Services, Inc.

$83K *
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Associates of Nursing (RN) required, BSN preferred
  • Current Massachusetts Registered Nurse (RN) license and BLS certification
  • 2+ years of nursing experience in community health settings
  • 1+ year in medical case management for complex patients preferred
  • Excellent verbal and written communication skills
  • Basic proficiency in Microsoft Office 365 and EMR systems like EPIC/OCHIN

Responsibilities

  • Assist in developing and implementing a comprehensive care plan with team and providers
  • Support patient care by collaborating with providers and care team members
  • Evaluate patient needs and adjust care plans accordingly
  • Manage high-risk patient populations with care management and education
  • Document care plans in EMR for high-risk patients
  • Act as a health educator for chronic disease populations through coaching and teaching
  • Participate in clinical tracking programs for compliance with health outcomes

Benefits

  • $5,000 sign-on bonus (half on hire, remainder after 90 days in good standing)
  • Flexible start times for day shifts
  • Full-time schedule of 40 hours per week
  • Opportunity to work in a collaborative team environment
  • Engagement in meaningful work with diverse patient populations
Full Job Description
Offering a $5000. Sign On Bonus!*

Minimum starting salary for this position is $40.00 hourly

We are seeking a talented Complex Care Nurse (RN) to join our team at the Harbor Community Health Center-Plymouth.

Role:

The Complex Care Nurse will aid in the development of and implement systems for population health-based and complex care nursing services at the top of the incumbent's license to patients in accordance with all applicable Massachusetts State Laws as well as regulations promulgated by the Department of Public Health and Harbor Health Services, Inc.

The Complex Care Nurse will assist in implementing programs to ensure our High-Risk Patient populations (Substance Use Disorder, Infectious Disease, Complex Care, Geriatric and Chronic Conditions) are properly managed including care coordination, consultations, tests, medication management, and patient education to move toward optimal wellness.

Responsibilities include:
  • In conjunction with the team and/or providers, assists in the development and implementation of a comprehensive plan of care.
  • Assists providers and Care Team members in caring for patients.
  • Assists providers with on-going assessments and evaluates needs and interventions based on the current status, adjusting the care plan as required, assuring compliance and understanding of the long-term plan.
  • Ensures HHSI High-Risk Patient population (Substance Use Disorder, Infectious Disease, Complex Care, Geriatric Chronic Conditions)are properly managed including care management, consultations, tests, medication management, and patient education to ensure or move toward wellness.
  • Ensures HHSI High- Risk Patients have a completed care plan documented in the EMR.
  • Actively demonstrates a working knowledge of nursing theory, techniques, principles, and practice to holistically care for the patient.
  • Participates in team, department and clinic meetings to learn, support process improvement and contribute to care plans as appropriate.
  • Acts as Health Educator for Complex Chronic Disease population (HIV, Hep C etc.)
  • Completes weekly patient visits as scheduled (individual or group visits).
  • Provides health coaching and teaching for common conditions (i.e. asthma, hypertension, diabetes...) through individual nurse visits, group visits and co-visits with other disciplines (clinical pharm, BH, nutrition, physicals...) as appropriate.
  • Assists in the orientation and training of new staff joining the Complex Care team, provides cross coverage and training for staff in similar roles as needed.
  • Communicates with staff, patients, and families demonstrating excellent written and verbal skills.
  • Maintains up to date knowledge of all medications (i.e., reactions, proper documentation and dosage requirements.
  • Administers medications and vaccinations to patients orally, topically, subcutaneously, intradermal and intramuscularly as order by provider or following standing orders policy.
  • Assesses information about the patients' physiological, psychological, sociological, and spiritual status.
  • Triages patients as needed.
  • Supports transitions of care through nurse visits after ED/Hospitalizations as appropriate.
  • Actively participates in clinical tracking programs to ensure compliance with clinical outcome measures, prevention and follow-up care.
  • As required and/or as appropriate, provides health care and disease management education as part of regular and nurse visits.


Requirements:

  • Associates of Nursing( (RN) required, BSN preferred
  • Current Massachusetts Registered Nurse (RN) and current BLS (Basic Life Support for Healthcare Providers) Certification required
  • 2 or more years of nursing experience in a community health related setting
  • 1 year of experience in medical case management, managing complex patients preferred
  • Excellent customer service skills, excellent verbal and written communications skills, ability to effectively work within both a team setting and independently
  • Ability to work effectively with economically, racially and linguistically diverse customers
  • Basic knowledge of Microsoft Office 365 including Word, Excel, Outlook and Teams, and use of Electronic Medical Record (EMR), EPIC/OCHIN preferred


The salary range and/or hourly rate listed is a good faith determination of base compensation that may be offered to a successful applicant for this position at the time of this job advertisement.

When determining actual base salary and/or rate, several factors may be considered as applicable (e.g. location, years of relevant experience, education, training, and other factors as permissible by law). As such, most offers will not be at the top of the salary range.

*sign on bonus half on hire and remainder after 90 days in good standing, former employees of HHSI not eligible.

Monday - Friday, day shift with occasional evening coverage, can be flexible on start time.
Full Time - 40 hours weekly

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