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Registered Nurse, Community Care Team Informational Posting

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Job Details
Job Order Number
Company Name
Northern Light Health
Physical Address

Presque Isle, ME 04769
Job Description

This is an INFORMATION ONLY POST. To apply for this position please
apply to job \#67022 on our career page *

  • LOCATION: This Position covers Aroostook County working with all AR
    Gould healthcare locations. **


This role is an invaluable part of Beacon Health’s population health
efforts. We believe that patient environments have both supports and
barriers which significantly impact their health. This RN position works
in close collaboration with the practice team to provide
home/environmental/social assessment to the team for consideration in
care planning. This RN promotes good health by working closely with the
patient to limit the impact of environmental and social barriers and
strengthen their supports in an effort to achieve better outcomes. This
position is an extension of Beacon Health’s practice based RN Care
Coordination services. Oversees clinical care to patients with chronic
disease, high cost of care, and/or less than ideal access to traditional
outpatient medical services. Collaborates with the Medical Team and
relevant community based supports to provide a model of care that
ensures the delivery of quality, efficient, and cost effective
healthcare services. Integrates evidence based clinical guidelines,
preventive guidelines, protocols, and other metrics in the development
of treatment plans that are patient-centric, promoting quality and
efficiency in the delivery of healthcare. Utilizes evidence based shared
decision making models and motivational interviewing to encourage
positive behavior change. Completes home/community visits. Reports to:
Community Care Team Program Manager.


- Manage utilization and practice metrics to refine the delivery of
care model to maximize clinical, quality and fiscal outcomes for the
- Monitor patient progress and promote early intervention in acute
care situations
- Provide safe transition of care across the continuum of care
- Promote and convene communication among all service providers on
behalf of and with the patient
- Provide patient education, related to chronic disease management,
home safety
- Promote patient independence, safety and self-management
- Demonstrate autonomy being accountable for their practice
- Demonstrate the ability to negotiate and influence individual and
group decision- making.
- Adapt to a fluid, dynamic and rapidly changing environment.
- Demonstrate leadership qualities in the areas of time management,
problem solving, decision making, priority setting, delegation,
organization, written/verbal communication and listening skills.
- Implement monitoring systems for high-risk member to prevent and/or
intervene early during acute exacerbations.
- Works with the primary care practice team to ensure appropriate
standing orders for acute exacerbation management (such as diuretic
titration protocol).
- Continuously evaluates all available patient information including,
laboratory results, diagnostic tests, utilization patterns and other
metrics to determine barriers to improved care, improved quality,
and decreased cost. Provides regular progress updates to members of
the care team.
- Collaborates with providers, including community based
organizations, to ensure smooth process in place when movement
between settings occurs.
- Provides home and community visits.


Needs to be professional as well as knowledgeable, responsible, and
accountable to provide patient care over the continuum and to assist in
improving quality, cost, and patient/service satisfaction outcomes.

Will be responsible for assessment, planning and implementation process
for a select group of patients in the outpatient setting.

Must be organized with the ability to self-motivate and prioritize a

variety of duties.

Proficient in computer literacy including but not limited to the
electronic medical record, electronic data entry, retrieval and report

Ability to work effectively with clinical and non-clinical staff and
community organizations

Understanding of community services and how to access them.

Must have willingness to learn about and work with people who have
behavioral health and substance abuse disorders.

Demonstrated ability to work with an interdisciplinary team.

Demonstrates excellent communication skills.

Demonstrates the ability to perform multiple tasks simultaneously.

Ability to motivate others

Ability to work with people from diverse backgrounds and experiences

Ability to openly address and acknowledge observed issues and concerns

Must pass background check.

Demonstrates proficiency in basic computer skills, including accurate
keyboard entry of data into relevant computer based databases and

Attention to detail, and ability to be flexible in performing a variety
of tasks.

Demonstrated ability to complete projects within designated timelines
and the ability to prioritize duties is required.

Demonstrates proficiency with Microsoft Word and Windows & Excel, and
the ability to learn various system software.

Demonstrates ability to use basic office equipment, computer, fax
machine, copier, calculator, etc.****


Registered Nurse with three to five years of recent (within the last 3
years) acute care experience or relevant experience required.

Licensed at an RN level by the State of Maine Board of Nursing.

Bachelor’s degree in Nursing preferred

Experience in home health nursing preferred.

Knowledge of the basic principles of care management and care
coordination required.

BLS Certification.

Valid Maine driver’s license.

Employee is exposed to environmental factors such as dust, fumes,
temperature, humidity, heights, machinery, driving.

Other duties or comments specific to this position: Expected to drive
on a wide range of roads and in inclement weather.

The specific statements shown in each section of this description are
not intended to be all-inclusive. They represent typical elements
considered necessary to successfully perform the job.

To view full details and how to apply, please login or create a Job Seeker account.