Complex Care Nurse

Plymouth MA

04 November, 2021

12:50 PM

Description

The Complex Care Nurse provides ensures that our High Risk Patient population (primarily our Office Based Addiction Treatment (OBAT) program patients) are properly managed including, referrals, consults, tests, medication management, and patient education to ensure or move toward optimal wellness. Position is Monday through Friday at the Harbor Community Health Center, 10 Cordage Park in Plymouth. Join a great team providing caring and convenient medical and behavioral health care in our community setting! Job Duties:• Ensures High Risk Patient population (OBAT, Complex Care) is properly managed including, referrals, consults, tests, medication management, and patient education to ensure or move toward wellness.• Ensures High Risk Patients have a completed care plan and documents in the EMR• Acts as Health Educator for Complex Chronic Disease population (HIV, Hep C)• Completes at least 16-20 scheduled patients facing clinical hours per week of individual or group visits.• Assists providers and Care Team members in caring for patients and acts as liaison between the patient and the care team.• Performs routine nursing care to patients, while utilizing age specific guidelines and standard precaution practices at all times.• Performs patient teaching for all patients and families.• In conjunction with team and/or provider, assists in the development and implementation of a comprehensive plan of care.• 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.• Communicates with all staff, patients, and families demonstrating excellent written and verbal skills.• Maintains knowledge of all medications, reactions, documentation, and dosage requirements.• Triages patients as needed.• Supports transitions of care through nurse visits after ED/Hospitalizations as appropriate.• Actively participates in the manual and automated clinical tracking programs to ensure compliance with clinical outcome measures, prevention and follow-up care.Required/Preferred Education, Experience and Skills:• Current MA Registered Nurse (RN), BSN preferred• 2-5 years of experience working with OBAT/Addiction patients highly desired• Excellent customer service and 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• Intermediate computer literacy experience including Electronic Medical Record (EPIC preferred) and Microsoft Office• Experience in a ambulatory and/or community health setting and experience in medical case management in acute care preferred. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.