Nurse Senior PCM Complex Care Specialist

Trinityhealth; Iowa (LA); On-site; USD 95,000 - 135,000; Full time

Job summary

Trinity Health is seeking a Nurse Senior - Complex Care Specialist to coordinate care for acutely hospitalized patients with highly complex needs. Embedded in the Acute Care Management team, you will drive advanced care coordination, remove barriers to progression, and support timely discharge planning while ensuring safe handoffs to outpatient and post‑acute resources.

This role requires leadership, collaboration across care teams, and adherence to nursing standards to improve patient outcomes

Qualifications

• RN licensure with ability to practice independently.
• Experience in complex care coordination and patient transitions.
• Ability to lead and mentor teams in a clinical setting.

Responsibilities

• Leads interdisciplinary complex care conferences to align patients, families, and care teams around goals, risks, barriers, and the inpatient plan.
• Ensures patient-centered care planning by identifying goals, values and informed decision-making for high-risk patients.
• Drives accountability for clear next steps, responsibilities, and discharge timelines with providers and leadership.
• Coordinates complex inpatient care through discharge, ensuring timely handoff to outpatient and post‑acute resources.
• Identifies system barriers and partners with leadership to resolve delays and improve care progression.

Job description

Employment Type:

Full time

Shift:

Day Shift

Description:

The Nurse Senior - Complex Care Specialist role is responsible for focused ownership and coordination of acutely hospitalized patients with highly complex medical, psychosocial, behavioral, and system‑driven needs. Embedded within the Acute Care Management team, this role provides sustained attention, advanced care coordination, and accountability for complex inpatient populations, partnering closely with care teams and leadership to remove barriers to progression, support timely discharge planning, and improve patient outcomes. While the role does not assume ownership of outpatient settings or teams, it is accountable for ensuring intentional coordination, connection, and effective handoff to appropriate outpatient, post‑acute, and population‑based resources as part of transitions of care. Adheres to MercyOne's performance expectations and upholds the Mission, Vision, and Values of MercyOne.

RN III - senior:

Practice is guided by nursing process & policy / procedure / standards. Maintains focused area of expertise for care / program & / or provides interventions or knowledge within niche areas of care / program; Advances professional / shared governance, collaborates inter & intra-professionally, delegates to others to advance care, assumes an expanded role & increased responsibility; Able to lead a small team; Serve as a unit / service / program nursing practice mentor & identify learning need of others.

TRINITY HEALTH ESSENTIAL FUNCTIONS

• Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions.
• Professional Nursing Practice: Acts independently & appropriately within license, scope of knowledge & experience in practice area; Continues to evolve with best evidence discoveries;
• Provides leadership & retains accountability for delegation, choices, decisions & outcomes;
• Collaborates with key stakeholders & contributes to quality & improvement practices & outcomes; Exhibits willingness to take on new & additional responsibilities; Embraces new ideas & cultural differences while managing competing priorities.
• Professional Nursing Process (ANA): Knows, understands, incorporates & demonstrates (document, teach, coordinate, advocate) standard elements of professional practice: Assess, Diagnose, Outcomes Identification / Solutions, Plan, Implement, Evaluate.
• Professional Development: Participates in own professional development by maintaining required competencies, licenses & certifications, identifying learning needs & seeking appropriate assistance or educational offerings; Supports the learning & development of others (e.g., staff, formal learners, patients, families, community).
• Compassion, Communication & Stewardship: Incorporates caring process (Caritas), advocacy & appropriate resource utilization as an essential component of nursing practice through concrete acts, interpersonal relationships & effective & respectful written, verbal & nonverbal communications.
• Environment of Care: Practices in an environmentally safe, professional manner; monitors & initiates corrections or evidence-based practices, including those for equipment & material resources; Promotes optimum physical &psychological behaviors; Influences effective, judicious & financially responsible use of resources.
• Maintains a Working Knowledge of applicable federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines in order to ensure adherence in a manner that reflects honest, ethical & professional behavior & safe work practices.

MERCYONE ESSENTIAL FUNCTIONS

• Leads interdisciplinary complex care conferences to align patients, families, and care teams around shared understanding of goals, risks, barriers, and the inpatient care plan.
• Ensures patient‑centered care planning by identifying, documenting, and supporting patient‑defined goals, values, and informed decision‑making, including high‑risk or non‑traditional pathways.
• Drives accountability for clear next steps, assigned responsibilities, and realistic timelines, partnering with providers and leadership to develop the safest possible plan of care and discharge.
• Coordinates complex inpatient care through discharge by ensuring timely connection, clear communication, and effective handoff to outpatient, post‑acute, and population‑based resources, promoting safe and seamless transitions across care settings.
• Applies advanced knowledge of workflows, payer and regulatory requirements, and community resources to identify system‑level barriers, partnering with leadership and external stakeholders to resolve delays and support efficient progression of care.
• Maintains advanced knowledge of internal workflows, payer requirements, regulatory expectations, and community resources impacting complex acute care patients.
• Identifies systemi