Complex Care Nurse

Job Description

Job Description

1. General Purpose of the Job
   The Complex Care Nurse serves as a key member of the Long Island Select Healthcare team, responsible for ensuring patients can access high-quality care regardless of location or travel limitations. This role focuses on bridging gaps in care delivery by coordinating virtual services, supporting in-home and community-based care, and serving as the central point of contact between patients, and care teams.

The Complex Care Nurse will actively support patients with complex needs, reduce barriers to care, and promote the effective use of virtual care technologies. When launched, this role will integrate with mobile health teams and provide on-site support to group homes and high-need populations.

1. Essential Duties & Responsibilities
   Patient Access & Care Coordination

• Serve as the primary liaison, ensuring patients receive timely care in their home or community setting.
• Identify and prioritizing high-risk patients who face barriers to accessing traditional care.
• Coordinate virtual care services, in-person support, and follow up care as needed.
• Facilitate transitions of care, including post-hospital or ER discharge follow-up within 24-48 hours to reduce readmissions.
• Assist patients with scheduling appointments, referrals, prior authorizations, and medication management.

Clinical Support & Monitoring

• Support remote patient monitoring and virtual care delivery, including tele-presenting and assisting with diagnostics (e.g., phlebotomy, testing).
• Analyze electronic health records (EHR) data to identify patients at risk for deterioration or poor outcomes.
• Ensure adherence to disease-specific care plans and treatment goals.
• Collaborate with providers.

Collaboration & Communication

• Act as a central communication hub between Long Island Select Healthcare providers, nursing teams, patient navigators, residential staff and external partners.
• Collaborate across disciplines to ensure coordinated, patient-centered care.
• Support group homes and community partners managing high volumes of complex patients.

Virtual Care Program Support

• Promote adoption and effective use of virtual care technologies among patients and staff.
• Monitor program effectiveness and contribute to quality improvement (QI) and performance improvements (PI) initiatives.

Documentation & Compliance

• Document all patient interactions and care activities in eClinicalWorks and other relevant platforms.
• Maintain strict patient confidentiality and compliance with all regulatory standards.
• Maintain awareness of healthcare policies, billing practices, and regulations related to virtual care.

1. Additional Responsibilities

• Participate in ongoing evaluation and improvement of virtual care programs.
• Support organizational goals to enhance access, quality, and outcomes of care.
• Perform other duties as assigned.

1. Supervisory Responsibilities
   None
2. Qualifications & Experience
   To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
3. Education and/or Experience
   Active New York State RN License required. Must be licensed by and currently registered with the New York State Department of Education. CPR/BLS certification required. eClinicalWorks experience preferred.
4. Necessary Skills & Abilities

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

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Reasoning Ability

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Computer Skills

To perform this job successfully, an individual should have basic to intermediate knowledge of Microsoft Office software (Outlook, Excel, Word), as well as Practice Management and Electronic Medical Record software – eClinicalWorks a plus).

Certificates, Licenses, Registrations

Clean valid NYS Driver's license.

Other Skills and Abilities

Interpersonal skills, organization & planning, problem solving, conflict resolution ability, assertiveness, strong teamwork & networking skills, ability to carry out job duties independently in the community. In addition, attendance at all mandated agency management training activities. Demonstrated ability to work effectively with culturally diverse populations.

1. Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel and talk or hear. The employee is frequently required to stand; walk and sit. The employee is occasionally required to reach with hands and arms; climb or balance; stoop, kneel, crouch or crawl, and taste or smell. The employee must occasionally lift and/or move up to 25 pounds.

1. Travel

Means and Ability to travel between sites, patient homes, and group homes required.

1. Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This role will hold a combination of in-office, remote, field based, and community settings with frequent travel to patient homes, group homes, and partner sites.

The noise level in the work environment is usually moderate.