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Complex Care Nurse

Apply Job Type Full-time Description

The Complex Care Nurse is responsible for establishing, implementing, monitoring, and evaluating patient-centered care plans for patients determined to be at high risk for poor health outcomes who would be best served with high-quality and cost-effective care coordination within the Patient Centered Medical Home (PCMH). The Complex Care Nurse interfaces with the primary care provider (PCP), health care team, patient, and their caregivers to promote patient-centered care and ensures the PCP maintains a central role in the care coordination.

Principal Duties and Responsibilities

  1. Routinely consults with patient's PCP, specialist providers, and other members of the PCMH team to identify high risk patients and initiate the patient-centered plan of care.
  2. Conducts virtual and in-person contact with identified high risk patients to establish rapport with the patient, provide patient/family health education, and conduct assessments (i.e. annual wellness visits).
  3. Develops and implements high-quality, cost effective plans of care that prevent disease exacerbation, improve outcomes, increase patient engagement, and manage risk status based on case management and utilization management principles, and payor rules and coverage.
  4. Implements the patient centered plan of care to include outreach and coaching activities to the patient and family/caregiver to support patient engagement. Serves as a key resource to the patient to address questions, concerns, and care needs by guiding and facilitating access to providers and services.
  5. Influences appropriate utilization of healthcare resources by coordinating patient care, encouraging patient involvement in disease and case management programs and conducting follow-up care with acute care or psychiatric admissions, emergency department visits, specialist visits, and sub-acute / rehabilitation care stays.
  6. Establishes a consistent schedule of communication and reviewing patient status and progress toward goals with involved providers, PCMH team, and the patient.
  7. Conducts case reviews and communicates with other healthcare team members throughout the continuum regarding patient care needs, utilization plan, and applicable follow up plans.
  8. Notifies PCP or practice leadership of over- and under-utilization of services and overall patient adherence to program goals.
  9. Maintains a registry of high-risk patients with documented completion of measures and interventions, care management interventions, and care plans that are documented in the electronic medical record.
  10. Participates in regular meetings with the PCMH team and operates within the PCMH model of care.
  11. Demonstrates a positive attitude with patients and establishes collegial relationships with the internal and external healthcare team members, agencies, and healthcare facilities.
  12. Demonstrates the ability to work independently and as an effective PCMH team member.
  13. Demonstrates initiative and commitment to continuously improve services and processes the positively impact quality and utilization of care.
  14. Meets agency participatory expectations and follows applicable Fenway Health policies and procedures.
  • Education: Bachelor's degree level or higher in nursing is required.
  • Current Massachusetts Registered Nurse (RN) license degree required on hire.
  • Certification in case management (CCM) or other applicable professional certification is preferred.
  • Three (3) years of experience in hospital, health plan, or community case management or utilization management role is preferred.
  • Detail orientation, excellent organizational skills, and the ability to multitask and work autonomously is required.
  • Effective interpersonal and communication skills and ability to work harmoniously with diverse groups of individuals is required.
  • Experience working in an ethnically, culturally, and racially diverse environment is required.
  • Proficient in the use of the computer and associated software, i.e., MS products is required.
  • Experience with working within a complex healthcare system with multiple product lines is preferred.
  • Ability to work harmoniously and effectively with colleagues, patients, clients and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin and immigrant status, religious or spiritual identity, disability (physical, mental, emotional and developmental), veteran status, and/or limited English proficiency.
  • Willingness to contribute towards Fenway's efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.

Working Conditions and Physical Requirements

1. OSHA Category 1: involves exposure to blood, body fluids, and/or tissues

2. Physical Requirements

  • Regularly required: sitting; using hands to manipulate objects/tools/controls; reaching with hands and arms; talking; hearing
  • Frequently required: lifting and/or moving up to 10 lbs.
  • Occasional required: lifting and/or moving up to 25 lbs.
  • Vision abilities required: close vision, distance vision, peripheral vision depth perception, ability to adjust focus

3. Noise Level: usually conversational

4. Shift

  • Required: ability to work a standard 37.5 hour workweek and rarely, a workday may require a shift up to 12 hours
We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, and a retirement plan with employer match. We also provide 12 paid holidays, paid vacation, and more.LGBTQIA+ identified persons, Black, Indigenous, and other people of color (BIPOC), and individuals from other historically underrepresented communities are strongly encouraged to apply.
Salary Range
$51,000.00 - $74,000.00
per Year
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Boston, MA, 02119, US