Complex Care Nurse

Grace Health; Battle Creek (MI); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical, vision, and dental insurance

401K match

Generous PTO accrual

Employee wellness program

Job summary

Grace Health in Battle Creek, Michigan is seeking a Complex Care Nurse to enhance healthcare services for patients with chronic diseases. This role involves planning, managing, and evaluating care for high-risk individuals, ensuring proper transitions, patient education, and quality monitoring.

The ideal candidate will have a Bachelor’s degree in nursing and three years of experience in nursing, with a focus on primary care. The position offers a competitive salary, comprehensive benefits, and a $1,000 sign-on bonus, without weekend or holiday shifts.

Qualifications

• Three years of professional nursing experience required.
• Experience in primary care environment preferred.
• Michigan Registered Nurse license is necessary.

Responsibilities

• Plan, arrange, and evaluate healthcare services for high-risk patients.
• Conduct chronic disease care management.
• Provide transitional care coordination for discharged patients.
• Educate patients about appropriate use of health services.
• Monitor quality measures and gaps in care.

Skills

Collaboration with care team providers

Chronic disease management

Patient education

Electronic Health Records (EHR) navigation

Education

Bachelor's degree in nursing

Tools

BLS certification

Job description

Are you driven by improving the care outcomes for patients with complex medical and psychosocial chronic diseases? Join our team as a Complex Care Nurse! Grace Health is seeking a Complex Care Nurse to plan, arrange, provide, and evaluate health care services for patients designated as high-risk or complex per Grace Health policy. No weekend or holiday shifts! Plus, benefits, competitive wages and more! $1,000 Sign-on bonus!

Benefits

• Medical, vision, dental, life, and disability insurance
• 401K match
• 8 paid holidays
• Generous PTO accrual
• Employee wellness program focusing on physical, mental, and financial wellness

Responsibilities

1. 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.
2. Conducts chronic disease care management for high-risk/complex individual patients, and those within identified target patient sub-populations.
3. Conducts transitional care coordination for patients newly discharged from an in-patient setting to reduce hospital re‑admission rates for Grace Health patients.
4. 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.
5. Assess patient’s health, pain, nutritional, psychosocial, behavioral, cultural, age‑specific, and learning needs.
6. Develops and implements plans to increase patient motivation, self‑management, and self‑efficacy in all aspects of chronic disease management and prevention.
7. Monitors quality measures related to individual and targeted sub‑populations to reduce gaps in evidence‑based care.
8. Provides referrals to community resources for patients/families.
9. Actively provides appropriate medical advice based on the registered nurse (RN) scope of practice.
10. Actively participates with community‑based initiatives related to care management and transitions of care.
11. Safely administers medication and treatments per standard of care, organization protocols and standing orders.
12. Actively participates in organizational quality committees and work groups.
13. Participates in professional development activities and maintains professional affiliations.
14. Maintains required licensure and certifications.
15. Adeptly navigates through patient Electronic Health Records (EHR).
16. Participates in CLIA and OSHA compliance and monitoring.
17. 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.

Requirements

• 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.