We are seeking a primary care nurse (RN) to join an innovative team that is committed to improving care for underserved patients with complex-needs. Reporting to the Field Team Physician, the Field Team Primary Care RN will be based in our office in Kalamazoo but will include travel throughout the local area.
The Field Team Primary Care RN, in a role designed to optimize RN scope of practice, provides emergent telephonic and in-person triage, chronic condition management, complex care coordination, patient education and wellness promotion, and select procedures that may include IV therapy, catherization, and complex wound care for a panel of complex-needs and homebound patients.
Our schedules allow providers to spend extended amounts of time with patients, allowing them to excel at relationship-based care, which is key to our care model. The Field Team Primary Care RN will work with members of a core field-based team (physician, advanced practitioner, clinical field team coordinator, patient engagement specialist) to address the social determinants of health, ensure safe transitions of care, maximize health outcomes, and prevent avoidable healthcare utilization. The Field Team Primary Care RN employs a propriety population health platform to close preventive care gaps per standing order, perform medication reconciliation, and support seamless patient care coordination.
This is an ideal position for a RN who has professional alignment to complex-need patients and underserved populations, enjoys a collaborative team-based work environment, and desires a challenging position that provides professional growth by allows practicing to the top of the RN license.
The Field Team Primary Care RN performs all duties in a manner that reflects the mission, vision, and core values of the Concerto Health care model. He or she demonstrates dedication to and an aptitude for innovation, quality improvement, role optimization, and team-based care. This individual demonstrates versatility, flexibility, and a willingness to work with constantly changing priorities with enthusiasm and a positive attitude and promote this same attitude among team members.
Essential Duties and Responsibilities
- Delivery of home- and community-based care (preventive, acute, chronic care management) on a consulting or continuing basis to complex patients in an 8-county area in southwest Michigan
- Provide clinical supervision, coaching, and mentorship to other members of the field team (clinical field team coordinator, patient engagement specialist)
- Collaborate with interdisciplinary team members – including physicians, advanced practitioners, pharmacists, pharmacy technicians, nurse care managers, patient services representatives, social workers and behavioral health professionals – to optimize care and outcomes
- Deliver timely healthcare services to patients after hospital discharge to facilitate continuing recovery and minimize readmissions
- Communicate closely with patients’ other healthcare providers so that primary and specialty care is well coordinated
- Conduct educational and quality improvement activities for Field Team members and other members of the interdisciplinary care team
- Build a successful home visit practice that carries an excellent reputation among area patients and healthcare professionals
- Performing other duties as assigned.
- Bachelor’s degree in Nursing from a four-year college or university
- Active license in the State of Michigan, or the ability to obtain one.
- Ideally three or more years’ experience since completion of residency, including home visit experience
- Public health and/or health administration studies, and/or experience in geriatric or palliative medicine/hospice preferred
- Must be skilled in providing care for the whole person, including patients living with mental illness and substance use disorders.
- Ideal candidates will want to work as advocates for their patients. They will also embrace the concept of team-work and mutual support of their colleagues, fostering a joyful work culture.
- Current CPR and BLS certification preferred
- Average to advanced computer & software skills (Microsoft Word, Excel, Outlook)
- Ability to work a flexible schedule, including periodic outreach duties evenings, nights, and weekends.
- Ability and means to travel as needed in a timely manner to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required. DRIVER REQUIREMENTS: Age 21; Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving with 7 years.