Description

Harbor Health Services is seeking a talented Complex Care Nurse to join our Primary Care Dept. at the Harbor Community Health Center - Plymouth.   

OFFERING $5000 SIGN-ON BONUS! *  

Role: 

The Complex Care Nurse will aid in the development of and implement systems for population health-based and complex care nursing services at the top of the incumbent’s 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 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.

Our position is offered with a full Benefits Package including Health, Dental and Vision, generous paid time off plus 11 paid holidays annually, free parking on site and competitive salary!  

Student loan repayment opportunities (National Health Service Corps/Public Service Loan Forgiveness and State Programs) available at our health center sites! Application cycles opening in early 2025! For more info click National Health Service Corps

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 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 High- Risk Patients have a completed care plan documented in the EMR.
• 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.
• 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.
• Conducts procedures according to policy while ensuring patient safety.
• Provides cross coverage and training for staff in similar roles as needed.
• Helps patients stay up to date with clinical care guidelines, immunizations and health maintenance tests.
• 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.
  
  

Requirements

Requirements: 
 • Current MA Registered Nurse (RN), BSN preferred, current BLS Certification required
 • 2 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 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 experience with Microsoft Office 365 including Word, Excel, Outlook and Teams experience with EMR (EPIC/OCHIN desired)
 • Ability to work effectively within a team setting and independently and able to work with a linguistically economically and racially diverse customers. 
 
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.

*half of bonus on hire and remainder after 90 days in good standing, former employees of Harbor Health not eligible.