Complex Care RN

Please note: Must have BSN

COMPLEX CARE NURSE
The Complex Care Nurse is a core member of the Field Team and provides the highest level of continuously improving quality medical care for a medically and socially complex patient population. This is an ideal position for an RN who has professional alignment to complex-need patients and underserved populations, enjoys a collaborative team-based work environment, and desires a challenging position that provides professional growth and allows practicing to the top of the RN license.
The Field Team is a robust, multi-disciplinary team that provides wrap-around services to patients in their homes to support the delivery of the right care, at the right place, at the right time, by the right care team member. The Field Team brings an intense focus on safe and effective transitions of care, preventing unnecessary utilization (emergency department visits, inpatient admissions, readmissions), and social determinants of health.
The Complex Care Nurse maintains a caseload of patients enrolled with the Field Team, including Hotspotter patients with complex medical/behavioral needs and vulnerable elderly populations at high risk for complications. The RN works in a deeply collaborative, multi-disciplinary model of care alongside a complex-care physician, advanced practitioner, social worker, health coach, clinical pharmacist, and clinical care navigator to develop and implement individualized care plans. Our schedules allow RNs to spend extended amounts of time with patients that allows them to focus on relationship-based care, which is key to our care model.
The RN performs all duties in a manner that reflects the mission, vision, and core values of the Concerto Health model. The RN demonstrates dedication to and an aptitude for innovation, quality improvement, role optimization, and team-based care. The RN is accountable for the delivery of quality, patient-centered, and team-based care to patients and families and serves as a resource for team members in the accurate and timely completion of patient care. The RN demonstrates versatility, flexibility, and a willingness to work with constantly changing priorities with enthusiasm and a positive attitude and promote this same attitude among team members.

Essential Duties and Responsibilities:
Leadership Responsibilities
Assists RN Practice Manager and Lead Physician with development and implementation team meetings and educational and quality improvement activities for Field Team Members and other members of the interdisciplinary care team
Coordinates with RN Practice Manager to assure nursing coverage during leaves of absence
Assists with the development and implementation of quality improvement initiatives
Field Team Responsibilities
Enthusiastically partners with Field Team Members to continuously improve quality of care, reduce cost of care, and improve both patient and staff satisfaction Performs all duties with a team-based focus – being available and willing to support the patient and team to make sure the patient receives the right care, at the right time, at the right place, and by the right care team member
Provides clinical supervision, coaching, and mentorship to clinical care navigators, licensed practice nurses, and health coaches; includes effective delegation of tasks to Field Team members
Participates in team huddles, team meetings, and multi-disciplinary team meetings
Builds a successful home visit practice that carries an excellent reputation among area patients and healthcare professionals

Care Delivery Responsibilities
Delivers home-and community-based care on consulting or continuing basis to complex patients, including intake appointments for new field team patients
Completes clinical risk assessment for new field team patients
Leads development and implementation of individualized care plans that are patient-focused, including the integration of evidence-based guidelines, preventive guidelines, and protocols in the development of care plans
Works with providers to develop and modify treatment plans that provides for continuity of care and improved patient outcomes
Engages patients in the health decision-making process and educate/facilitate advance care directives
Delivers timely healthcare services to patients after hospital discharge to facilitate continuing recovery and minimize readmissions, including independent RN and collaborative hospital discharge follow-up appointments
Collaborates with interdisciplinary team members – including physicians, advanced practitioners, pharmacists, pharmacy technicians, health coaches, nurse care managers, field team coordinators, social workers, and behavioral health professionals – to optimize care and outcomes
Performs emergent telephonic triage
Provides patient education, including anticipatory guidance, information about chronic disease management, disease prevention and promotion of health maintenance; includes implementation of standing orders for chronic disease management
Performs select procedures, including complex wound care, IV therapy, medication administration
Manages all patient tasks and patient/provider follow-up according to tasking guidelines
Maintain own daily schedule of patients
Accurately document patient care in the electronic health record, including closing all visit notes within 72 hours

Additional Duties
Demonstrates knowledge of and compliance with laws and regulations governing area of responsibility
Maintains a safe work environment, including proper hazardous waste management for all visits
Participates in the onboarding and training of new Complex Care Nurses and other Field Team Members
Performs other duties and responsibilities, as required
Maintains a safe work environment

Qualifications
Bachelor’s degree in Nursing from a four-year college or university
Active license in the worked-in state, or the ability to obtain one.
Ideally two or more years’ experience since completion of residency, including home visit experience
Public health and/or health administration studies, and/or experience in geriatric or palliative medicine/hospice preferred
Must be skilled in providing care for the whole person, including patients living with mental illness and substance use disorders.
Ideal candidates will want to work as advocates for their patients. They will also embrace the concept of team-work and mutual support of their colleagues, fostering a joyful work culture.
Current CPR and BLS certification preferred
Average to advanced computer & software skills (Microsoft Word, Excel, Outlook)
Ability to work a flexible schedule, including periodic outreach duties evenings, nights, and weekends.
Ability and means to travel as needed in a timely manner to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required.

Driver requirements
Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving with 7 years.

 

Company Description:
Chemistry Talent is a full-cycle recruitment consultancy.
At Chemistry, we take the time to get acquainted with you. Our goal is to find the right talent and best fit for the job. That’s what we at Chemistry do best. Whether you are looking to fill a position in your company, or searching for that dream job, we’ve got you covered. We do the heavy lifting, so you don’t have to.

We partner with both our candidates and clients to provide high-quality results quickly and efficiently.  Communication is our business, so we constantly strive to keep you in the loop during all phases of your hire or application.

Our candidates enjoy the smooth process and hands-on relationships with our recruiters, and our clients appreciate our attention to detail and speed to market. 

At Chemistry, we provide staff for contract positions, contract-to-hire, and permanent employment.  All of our candidates are professionally vetted, and come from all career backgrounds and levels.  Regardless of the length of time or scope of work, we have the talent you need.