Complex Care Nurse (RN required)

West County Health Centers (WCHC) provides comprehensive and quality health care services to the communities of Western Sonoma County. We are a cohesive team of health care providers, support staff and volunteers dedicated to wellness, affordability, and excellence of care. Come and be a part of an amazing team!

JOB SUMMARY: The Complex Care Nurse is responsible for providing case management to a subset of the population with multiple chronic conditions, high utilization and other factors that put the patients in a high risk category of care. Providers at the site will be able to refer patients with high utilization of the ED, inpatient admissions and/or pharmacy costs to the Complex Care Nurse. Other qualifying criteria includes poor management of chronic conditions, medication adherence support, poor compliance with treatment plan, support with complex psychosocial needs, End of Life and Palliative service linkage and /or dual diagnosis and substance use disorder.

Position is posted for 40 hours/week and is located fully on-site at our Russian River Health and Wellness Center in Guerneville, California.

RESPONSIBILITIES:

• The Complex Care Nurse will receive Inpatient Discharge Reports of patients enrolled in our High Risk Care Management Program and will do Nurse Start visits for Inpatient Discharge Follow Up care.
• Utilizing a list based on claims data, diagnoses and other risk factors, primary care teams will refer patients to the Complex Care Nurse.
• A patient who meets the criteria and is enrolled in the program will receive more intensive nurse care management for 6-12 months. There will be a rolling admission to and discharge from the Care Management Program.
• The Complex Care Nurse will perform care coordination and patient education by phone and in face to face visits with the patient.
• The goal of the referral is to reduce utilization, improve management of chronic conditions, assist with system navigation and connect the patient to resources and support.
• The Complex Care Nurse will be an extended member of the care team and will work collaboratively with providers and other members of the care team.
• Assess, identify problems, plan goals, monitor and evaluate client plans and develop strategies that meet the clients’ immediate and long term needs.
• Assist with home care referrals for high risk patients.
• Collaborate with the Behavioral Health and Psych Team in assessment, diagnostic, and intervention services for clients who are overwhelmed by an acute episode, have a dual diagnosis or for those others who have limited self-care abilities.
• Participate in activities related to addressing the social determinants of a patient’s health.
• Assist in the coordination of warm hand-offs or “Transfer of Trust” between Care Team, Behavioral Health Staff, or other support services during the office visit.
• Participate in the adoption and implementation of new technologies and activities that improve patient care and clinic efficiencies.

MINIMUM REQUIREMENTS:

• Current California Registered Nurse License
• Current CPR certification
• Must be able to perform the physical demands of the job.
• Basic office and equipment safety knowledge and practice
• Basic computer skills
• Excellent communication skills

PHYSICAL REQUIREMENTS:

• Ability to bend and move arms with sufficient range of motion to complete patient related requirements, may need to assist patients onto exam table, must be able to lift 30 lbs., bend, kneel and twist as needed and hearing is required for patient assessments.
• Prolonged standing and occasional sitting required.
• Must be able to perform the essential duties with or without accommodations. Must possess basic office and equipment safety knowledge and practice.

We comply with applicable federal and state civil rights laws and do not discriminate based on race, ethnicity, color, national origin, citizenship, alienage, religion, creed, sex, sexual orientation, gender identity, gender expression, age, disability, or any other status protected by applicable laws.

Job Type: Full-time

Pay: From $42.00 per hour

Benefits:

• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Experience:

• Case management: 1 year (Preferred)
• Nursing: 1 year (Preferred)

License/Certification:

• California RN License (Preferred)
• CPR Certification (Preferred)

Ability to Commute:

• Guerneville, CA 95446 (Required)

Work Location: In person

Salary : $42