Registered Nurse (RN) - Team-Based Primary Care

OUTER CAPE HEALTH SERVICES INC•Harwich, MA

3d•$33 - $45•Remote

About The Position

Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions. Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod. OCHS now cares for more than 18,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it and validating that staff are working at the top of their licensures, are the foundations of this model. At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives. The Remote Nurse is a key member of the Outer Cape Health Services (OCHS) clinical team, delivering high-quality, patient-centered care in a virtual environment. This position supports providers, medical assistants, behavioral health specialists, and other team members to ensure timely, coordinated, and comprehensive care for patients. The remote nurse will focus on triage, care coordination, chronic disease management, and panel management, leveraging technology and clinical protocols to maintain continuity of care and close care gaps.

Requirements

BLS/CPR certification required.
Minimum of 1–2 years of clinical nursing experience preferred, ideally in a primary care or community health setting.
Experience or desire to work in team-based care model.
Bachelor of Science or Associates in Nursing from an accredited school of nursing by AACN.
Current Registered Nurse (RN) license from the Massachusetts State Board of Registration.
Maintain and enhance professional nursing skills and knowledge by attending continuing education programs.
Excellent interpersonal skills, communication skills, organizational abilities, computer experience, and the ability to work within a collaborative team setting.
Excellent written and verbal communication skills – bi-lingual helpful.
Proficiency in computer skills including EPIC, Outlook, Microsoft office, OneDrive etc.
Excellent judgment and ability to solve problems in a timely manner.
Ability to adhere to strict confidentiality standards.
Demonstrated ability to work effectively both as a team member and independently.
Demonstrated ability to work in a culturally diverse and inclusive environment.
Fully remote position with reliable high-speed internet required.
Occasional on-site meetings or trainings may be required.
Must maintain a HIPAA-compliant home office environment for patient confidentiality.

Responsibilities

Conduct nurse visits via telehealth for chronic disease management, blood pressure checks, INR reviews, medication education, and post-hospital discharge follow-up.
Perform triage using approved clinical protocols, assess patient needs, and coordinate same-day care when necessary.
Exhibit a high level of clinical acumen and decision-making to address patients’ acute and chronic needs as part of a highly functioning team.
Reinforce treatment plans for chronic conditions (e.g., diabetes, hypertension, asthma).
Process medication refill requests per standing protocols and ensure accurate documentation.
Educate patients on proper use of medical equipment, prescribed regimens, and other self-care practices.
Provide a patient-centered experience by addressing questions, explaining procedures or testing, and connecting patients with community resources or support programs.
Collaborate with providers and team members to close care gaps and ensure follow-up on labs, referrals, and preventive services.
Participate in pre-visit planning, leveraging standing orders to improve care delivery.
Review dashboards and outreach to patients to schedule recommended visits and screenings.
Assist with care transitions and follow-up after hospital or ED discharge.
Actively participate in virtual team huddles, case conferences, and interdisciplinary care planning.
Support population health initiatives and quality improvement projects to advance OCHS’ strategic goals.
Facilitate coordination with specialty care, social services, and community-based resources to meet patient needs.
Maintain accurate and timely documentation in the Electronic Medical Record (EMR) per OCHS policies.
Manage all assigned in-baskets including telephone encounters, patient messages, and overdue results.
Perform pre-visit medication reconciliation when indicated.
Communicate abnormal and normal results promptly to providers and patients.
Ensure compliance with HIPAA, infection control standards, and organizational clinical protocols.
Promote teamwork by collaborating with providers, Medical Assistants, and Patient Service Representatives.
Seek guidance from the Nurse Manager for escalated concerns or complex clinical issues.
Contribute to a culture of safety by adhering to National Patient Safety Goals (e.g., patient identification, medication safety, infection prevention).
Maintain patient records with accurate and timely documentation in the Electronic Medical Record (EMR) in accordance with OCHS policies.
Ensure compliance with infection control standards, medication safety, and clinical protocols.
Maintain patient privacy and confidentiality of information at all times in accordance with OCHS policies and HIPAA.
Attend periodic staff meetings.
Adhere to OCHS policies.
Adhere to OCHS values and principles.