Complex Care Nurse

Harbor Health Services, Inc.•Boston, MA

2d•Onsite

About The Position

Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and support services to more than 34,000 patients in Boston, the South Shore, and Cape Cod. Harbor Health also operates two Programs for All-Inclusive Care for the Elderly in Mattapan and Brockton, providing comprehensive healthcare, transportation and social services for more than 580 frail elders who continue to live with dignity and independence in the community and a Woman, Infants and Children (WIC) Nutrition Program. We are seeking a talented Complex Care Nurse (RN) to join our team at the Daniel Driscoll-Neponset Health Center. 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.

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

Nice To Haves

BSN preferred
1 year of experience in medical case management, managing complex patients preferred
EPIC/OCHIN preferred

Responsibilities

In conjunction with team and/or provider, 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.