Complex Care Staff Nurse

Job Description: OFFERING $5000 SIGN-ON BONUS! * 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 and a WIC Nutrition Program. To help further the mission of Harbor, we are looking for a talented Complex Care Nurse to join our Family Practice Dept. at the Harbor Community Health Center-Plymouth. Our position is offered with a GREAT Benefits Package including Health, Dental and Vision, Life and Disability Insurance, generous paid time off plus an additional 11 paid holidays annually, parking on site and competitive salary! Student loan repayment opportunities (National Health Service Corps/Nurse Corps, Public Service Loan Forgiveness and State Programs) available at our health center sites! FOR MORE INFO CLICK HERE: Nurse Corps Loan Repayment Role: 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. Hours are Monday through Friday, 8:00 AM - 4:00 PM, no weekends, no evenings!! 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, 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 time, as directed per Harbor policy.Takes thorough and accurate patient history. Communicates with staff, patients, and families demonstrating excellent written and verbal skills.Consistently seeks educational resources to broaden knowledge base of various age groups, diseases, and best practices.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. Helps patients stay up to date with clinical care guidelines, immunizations and health maintenance tests.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. Follows HHSI policy when disposing of biohazardous materials, labeling and handling all materials. Requirements: Associates of Nursing( (RN) required, BSN preferred2 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 skillsExcellent verbal and written communications skillsAbility to effectively work within both a team setting and independentlyAbility to work effectively with economically, racially and linguistically diverse customersBasic knowledge of Microsoft Office 365 including Word, Excel, Outlook and Teams, and use of Electronic Medical Record (EMR), EPIC/OCHIN preferredA ll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status. Sign on bonus offered, one half on hire and remainder after 90 days in good standing, former employees of Harbor Health not eligible.Monday through Friday 8:00 AM - 4:30 PMNo weekends/no eveningsFull Time 40 hours