Are you a nurse? Do you have the passion to coordinate the provision of healthcare services and improve care outcomes for patients with complex medical and psychosocial chronic diseases? Join our team as a Complex Care Nurse! You will plan, arrange, provide, and evaluate health care services for patients designated as high-risk or complex per Grace Health policy.
EXAMPLES OF DUTIES: (This list may not be all inclusive.)
- Applies the principles of the nursing process to improve care outcomes for complex, high-risk patients with chronic medical and psychological/behavioral diseases, through collaboration with care team providers, support staff, and behavioral health department.
- Conducts chronic disease care management for high-risk/complex individual patients, and those within identified target patient sub-populations.
- Conducts transitional care coordination for patients newly discharged from an in-patient setting to reduce hospital re-admission rates for Grace Health patients.
- Identifies and educates patients who are high utilizers of Grace Health or emergency departments about appropriate use of services, and develops individual plans to improve appropriate use of services at those facilities.
- Assess patient’s health, pain, nutritional, psychosocial, behavioral, cultural, age-specific, and learning needs.
- Develops and implements plans to increase patient motivation, self-management, and self-efficacy in all aspects of chronic disease management and prevention.
- Monitors quality measures related to individual and targeted sub-populations to reduce gaps in evidence-based care.
- Provides referrals to community resources for patients/families.
- Actively provides appropriate medical advice based on the registered nurse (RN) scope of practice.
- Actively participates with community-based initiatives related to care management and transitions of care.
- Safely administers medication and treatments per standard of care, organization protocols and standing orders.
- Actively participates in organizational quality committees and work groups.
- Participates in professional development activities and maintains professional affiliations.
- Maintains required licensure and certifications.
- Adeptly navigates through patient Electronic Health Records (EHR).
- Participates in CLIA and OSHA compliance and monitoring.
- Although each position has its own unique duties and responsibilities, please refer to the policy on Job Descriptions for details that apply to every position.
Knowledge, Skills and Abilities:
- Ability to work both independently and as part of cross functional teams.
- Ability to analyze, plan, organize, prioritize, and problem solve effectively and creatively.
- Ability to effectively communicate verbally and in writing with internal and external stakeholders. Ability to react calmly and effectively in emergent situations.
- Ability to interpret, adapt, and apply guidelines and procedures.
- Ability to establish and maintain positive, effective working relationships with patients, employees, and a variety of community representatives, and organizations.
- Knowledge of professional nursing theory and practice to provide and evaluate patient care.
- Knowledge of organizational policies, regulations and procedures to administer patient care.
- Knowledge of medical equipment and instruments to administer patient care.
- Knowledge of common safety hazards and precautions to establish a safe work environment.
- Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care management.
- Skill in identifying problems and recommending solutions.
- Skill in preparing and maintaining records, writing reports, and responding to correspondence.
Education: Bachelor’s degree in nursing from an accredited college preferred.
Experience: Three years of professional nursing experience required. Minimum three years of experience in a primary care environment preferred.
Certificate/License: Possession of a Michigan Registered Nurse license, Current BLS certification