Complex Care Nurse

Offering a $5000 Sign On Bonus!*

Harbor Health Services is seeking for a talented Complex Care Nurse (RN) to join our team at the Daniel Driscoll-Neponset Health Center in Dorchester
.

Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off plus 11 additional Holidays and much more!

The Complex Care Nurse will aid in the development of and implement systems for population health-based and complex care nursing services. 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, consults, tests, medication management, and patient education to move toward optimal wellness.

• 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, consults, 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).
• Acts as liaison between the patient and the care team.
• 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.
• Performs routine nursing care to patients, while utilizing age specific guidelines and standard precaution practices at all times, as directed per Harbor policy.
• Takes thorough and accurate patient history.
• 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.
• Provides cross coverage and training for staff in similar roles as needed.
• 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.

• Associates of Nursing required, BSN preferred
• Current Massachusetts Registered Nurse (RN) and current BLS (Basic Life Support for Healthcare Providers) Certification required
• 2 years of nursing experience in a community health related setting highly desired
• 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
• Experience with Office 365 including Word, Excel, Outlook and Teams, and…