Complex Care Nurse RN

•    In conjunction with the team and/or providers, 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 HHSI High-Risk Patient population (Substance Use Disorder, Infectious Disease, Complex Care, Geriatric Chronic Conditions)are properly managed including care management, consultations, tests, medication management, and patient education to ensure or move toward wellness.
•    Ensures HHSI High- Risk Patients have a completed care plan documented in the EMR.
•    Actively demonstrates a working knowledge of nursing theory, techniques, principles, and practice to holistically care for the patient. 
•    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). 
•    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.
•    Assists in the orientation and training of new staff joining the Complex Care team, provides cross coverage and training for staff in similar roles as needed.
•    Communicates with staff, patients, and families demonstrating excellent written and verbal skills.
•    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. 
•    Triages patients as needed.
•    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. 
•    As required and/or as appropriate, provides health care and disease management education as part of regular and nurse visits.