Complex Care Nurse

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.

Essential Duties & Responsibilities

• Serve as the primary liaison, ensuring patients receive timely care in their home or community setting.
• Identify and prioritize high-risk patients who face barriers to accessing traditional care.
• Care coordination: 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.
• Aid patients with scheduling appointments, referrals, prior authorizations, and medication management.
• Support clinical care: Support remote patient monitoring and virtual care delivery, including tele-presenting and assisting with diagnostics (e.g., phlebotomy, testing).
• Analyze 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 to ensure coordinated, patient-centered care.
• Support group homes and community partners managing high volumes of complex patients.
• Promote adoption and effective use of virtual care technologies among patients and staff.
• Maintain program effectiveness and contribute to QI and PI initiatives.
• Document all patient interactions and care activities in eClinicalWorks and other relevant platforms.
• Maintain strict patient confidentiality and comply with all regulatory standards.
• Maintain awareness of healthcare policies, billing practices, and regulations related to virtual care.
• 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.

Qualifications & Experience

• Active New York State RN License required.
• Licensed by and currently registered with the New York State Department of Education.
• CPR/BLS certification required.
• eClinicalWorks experience preferred.
• Necessary skills: Reasoning, communication, interpersonal skills, organization, problem-solving, teamwork, networking, assertiveness, ability to work with diverse populations, physical demands, travel, noise levels, work environment, and physical abilities.