The Complex Care Nurse for the Elder Service Plan provides nursing services at the top of his/her 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 ensures our High Risk Patient population (Complex Care, Geriatric) is properly managed including, referrals, consults, tests, medication management, and patient education to ensure or move toward optimal wellness.
Essential Functions include:
• Acting as liaison between the patient, patient families and the care team, as well as with the patient and provider.
• Participating in the interdisciplinary (IDT) team, department and clinic meetings to learn and support process improvement and contribute to care plans as appropriate.
• Facilitating IDT team and care planning meetings.
• Providing health coaching and teaching for common conditions (i.e. asthma, hypertension, diabetes…).
• Supporting transitions of care through nurse visits after ED/Hospitalizations.
• As required and/or as appropriate, providing health care and disease management education as part of regular and nurse visits.
• Ensuring HHSI High Risk Geriatric Patients have a completed care plan and plan is documented in the EMR.
Required/Preferred Education, Experience and Skills;
• Successful completion of a nursing program (RN), BSN preferred.
• 1 year of experience in medical case management in acute care, geriatric/ambulatory care setting preferred.
• 1 year of experience working with a Geriatric population required.
• Current MA RN License, Current CPR/BLS required.
• 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.
• Basic computer literacy (basic knowledge of keyboarding, and use of the mouse, scheduling software, principals of windows and Microsoft Office) and EMR.
• Experience in a community health setting preferred
•Ambulatory care or health insurance environment preferred.
Harbor Health is an Equal Opportunity Employer M/F/V/D.
Additional Application Instructions
Please apply online at link provided or go to https://www.hhsi.us/about-us/join-our-team
Reference https://www.linkedrn.com/jobs/15141709-complex-care-nurse-at-harbor-health-services-elder-service-plan-of-brockton
Reference : Complex Care Nurse jobs
Source: http://jobrealtime.com/jobs/technology/complex-care-nurse_i6233
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