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    Medical / Health - Nurse - Boston, MA, United States - Tufts Medical Center

    Tufts Medical Center
    Tufts Medical Center Boston, MA, United States

    3 weeks ago

    Default job background
    Description
    We're saving lives, building careers, and reimagining healthcare. This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders.

    Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient's plan of care as directed.

    Provides professional nursing care to patients. Requires a nursing license.

    A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.

    The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.

    A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.


    Typically responsible for:

    managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

    The position, utilizing the case management process, will work closely with the child/family, the primary Care physician, and all members of the health care team to ensure that a specific population of patients receives comprehensive and coordinated through the continuum.

    The position conducts comprehensive clinical assessment, develops a patient/family centered care plan including goals of care with the entire complex care team.

    The position engages the patient and family through coaching with the focus of preparing for optimum health outcomes while preventing admissions, readmissions and adverse events.

    The position assesses, plans, implements, coordinates and evaluates the plan of care in partnership with the family and other members of the health care team.


    Three (3) years of experience in care management, ambulatory nursing, community nursing, home care, acute, or subacute setting.

    Bachelor of Science in Nursing (BSN)
    Specialty nursing certifications

    Prepares for patient interaction by gathering information from reviewing the patient's medical record when available and communicating with the PCP and other members of the health care team.

    Completes assessments upon enrollment, transition in care and changes in health status.
    Coordinate all aspects of care for patients through continuum.

    Assess the child/family to obtain information to identify and to prioritize, in partnership with the families, the child's health conditions and establish goals that are patient specific.

    This includes self -management goals.
    Communicates abnormal findings and concerns in a timely manner to the provider/other members of the care team. Conducts medication reconciliation with every transition of care and provides education and consultation with Pharmacist.
    Develops a care plan with the patient, family; providing all information to the PCP and the health care team.
    Conducts home assessments to address health care needs especially home safety needs.
    Documents the assessments, interactions and the care plans within the EMR. Utilizes identified teaching materials and evidence based best practice for teaching patients/families/community.
    Undertakes quality improvement activities to improve the care management program.
    Maintains collaborative, team relationship working with TMIN staff and all affiliated agencies. Works with Medicare and commercial population

    Possesses and applies the skills and knowledge necessary to plan for and provide care to patients and their families throughout the life span, with consideration of developmental age as well as chronological age.

    Ability to work effectively with children and families that reflect the full diversity of family structures, cultural patterns, spiritual beliefs and communities.

    Ability to interpret age specific data and response to care; Ambulatory work environment along with inpatient, community and home care / patient care areas.

    Occasional exposure to hazardous chemicals/sick patients/bodily substances, extreme noise, radiation.
    Work requires occasional/frequent/continuous typing/computer keying, lifting/assisting/positioning patients, patient treatment instruments/equipment.

    Commitment and expertise in family centered care.
    Proficiency in relevant Information Systems such as Windows products, EMR.
    Knowledge and skill in complex care conditions, population health and community resources.

    Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts.

    Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network.

    We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine.

    Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law.

    We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

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