Complex Care Nurse Specialist
5 days ago
We are seeking a skilled Complex Care Nurse to join our team at Grace Health. As a Complex Care Nurse, you will play a critical role in improving the care outcomes for patients with complex medical and psychosocial chronic diseases.
About the Role:The Complex Care Nurse will be responsible for planning, arranging, providing, and evaluating health care services for patients designated as high-risk or complex per Grace Health policy. This role requires a strong understanding of chronic disease management, care coordination, and patient education.
Key Responsibilities:- Apply the principles of the nursing process to improve care outcomes for complex, high-risk patients with chronic medical and psychological/behavioral diseases.
- Conduct chronic disease care management for high-risk/complex individual patients, and those within identified target patient sub-populations.
- Conduct transitional care coordination for patients newly discharged from an in-patient setting to reduce hospital re-admission rates for Grace Health patients.
- Identify and educate patients who are high utilizers of Grace Health or emergency departments about appropriate use of services, and develop 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.
- Develop and implement plans to increase patient motivation, self-management, and self-efficacy in all aspects of chronic disease management and prevention.
- Monitor quality measures related to individual and targeted sub-populations to reduce gaps in evidence-based care.
- Provide referrals to community resources for patients/families.
- Actively provide appropriate medical advice based on the registered nurse (RN) scope of practice.
- Actively participate with community-based initiatives related to care management and transitions of care.
- Safely administer medication and treatments per standard of care, organization protocols and standing orders.
- Actively participate in organizational quality committees and work groups.
- Participate in professional development activities and maintain professional affiliations.
- Maintain required licensure and certifications.
- Adeptly navigate through patient Electronic Health Records (EHR).
- Participate in CLIA and OSHA compliance and monitoring.
- Bachelor's degree in nursing from an accredited college preferred.
- Three years of professional nursing experience required. Minimum three years of experience in primary care environment preferred.
- Possession of a Michigan Registered Nurse license and current BLS certification.
- Seasonal Flu Vaccine.
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