Wellness Nurse

Springfield, MA

General Description: 

The Wellness Nurse plays a critical role in the integration and delivery of chronic disease management and wellness programming and will provide clinical expertise across specialty clinics and programs  focused on diabetes, prediabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, and asthma.  The Wellness Nurse will work under the direction of the Wellness Nurse Manager to maintain a clinical  schedule providing direct patient care and individualized wellness plans for patients managing chronic  conditions, as well as support care teams in the delivery of chronic disease management and prevention  services. In support of the agency’s mission to eliminate health disparities through evidence-based,  culturally-responsive health promotion programming, the Wellness Nurse will support the Wellness  Center offering a range of physical activity and nutrition programs, as well as collaborate across a team of  Wellness Community Health Workers. 

Reports to: Wellness Nurse Manager 

Supervises: N/A 

Salary/Status: Exempt 

Hours: 40 Hours/Week 

Note: This position is grant-funded. 

Minimum Requirements:  

∙ Nursing license (RN/LPN) in state of Massachusetts. 

∙ Oral and written fluency in English (fluency in another language a plus, such as Spanish, Arabic,  Russian, Vietnamese, or Nepali).  

∙ Experience providing direct patient care; in particular, experience in complex care, chronic  disease management, nutrition, or exercise physiology settings will be prioritized. 

∙ Prior training/certification in facilitation of evidence-based wellness programs will be prioritized,  such as Chronic Disease Self-Management, Diabetes Self-Management, Asthma Home Visiting,  Self-Monitored Blood Pressure, or other related curricula. 

∙ Complete proficiency in Microsoft Office (Word, Excel, and PowerPoint) and Google Workspace  (Email, Calendar, Drive, Docs, Sheets, and Slides) applications.  

∙ Experience (or strong interest/willingness) in facilitating group-based health education activities. ∙ Ability to independently and effectively balance and prioritize personal daily tasks, including  clinical visit schedules, educational programming, and case management.  

∙ Ability to think critically, identify inefficiencies and solutions, and proactively take action to  support clinic and program needs. 

∙ Ability to work at a fast pace, manage numerous complex projects and teams, prioritize and  accommodate last-minute requests effectively, and tolerate pressure with relative equanimity. ∙ Ability to develop effective partnerships with and coordinate specialty clinical activities for a  team of champion medical Providers, Nurses, Medical Assistants, and contracted specialists.  ∙ Strong professional communication and correspondence skills. 

∙ Ability to provide constructive feedback, training, support, and supervision to clinical support  staff and community-facing staff. 

∙ Ability to listen actively, demonstrate responsiveness to team needs/requests, and integrate  feedback thoughtfully and promptly.  

∙ Ability to demonstrate cultural sensitivity with staff, teams, patients, stakeholders, and partners  representing diverse cultures, ethnicities, sexual orientations, gender identities, socioeconomic  statuses, educational backgrounds, worldviews, literacy levels, and languages. 

∙ Utmost discretion and compliance with state, federal, and internal policies when handling  confidential patient information. 

∙ Reliable transportation and flexibility to travel daily, often spontaneously, to multiple primary  care sites to provide patient care, clinical support, or administrative support as needed.  

∙ Flexibility to attend out-of-town trainings, conferences, and outreach on occasional evenings and  weekends. 

∙ Ability to work full-time, on-site, and in-person providing direct patient services.

Principle Responsibilities and Duties: 

∙ Under the direction of the Wellness Nurse Manager, provide clinical support for a variety of  evolving grants, programs, and research projects focused on chronic disease management and  wellness, including diabetes, prediabetes, hypertension, dyslipidemia, cardiovascular disease,  stroke, and asthma. 

∙ Deliver direct patient care across specialty chronic disease management clinics and programs,  primarily the Cardiovascular Disease (CVD) Virtual Care Plan Program, Self-Monitored Blood  Pressure Program, Asthma Clinic, and Spirometry Clinic. 

∙ Support the design of workflows and strategic approaches to integrate grant-required objectives  into clinical service delivery. 

∙ Support the Wellness Nurse Manager with day-to-day operations of clinics and programs,  including management of inventory, scheduling, and referrals. 

∙ Deliver direct clinical services (in-person visits, telehealth visits, triage, and care coordination) to  a large panel of patients enrolled in CVD Virtual Care Plan Program, Self-Monitored Blood  Pressure Program, Asthma Clinic, and Spirometry Clinic. Maintain a personal schedule at three  primary care sites within the established RN/LPN scope of practice, including but not limited to: o Provide point-of-care testing (e.g., hCG, urinalysis); administer medications and  

immunizations; order labs; provide wound care; check vital signs; and perform  

tympanometry, cardiography, and other diagnostic tests as needed.  

o Develop comprehensive, individualized self-management care plans and provide  

counseling and education to support patients in effective management of chronic health  

conditions.  

o Provide education on use of self-monitoring devices and strategies; utilize data from self monitoring devices to inform self-management care plans in collaboration with  Providers. 

∙ Collaborate with Primary Care Providers, Nurses, Medical Assistants, Clinical and Retail  Pharmacists, Cardiometabolic Team, Asthma Team, and Quality and Analytics Teams to ensure  consistency across program workflows, promotions, and reporting of outcomes across chronic  disease management programming, including CVD Virtual Care Plan Program, Self-Monitored  Blood Pressure Program, Hypertension Clinic, Asthma and Spirometry Clinics, Diabetes Clinic,  and Medication Therapy Management Clinic. 

∙ Collaborate with Wellness Specialists delivering physical activity education, and Wellness  Community Health Workers delivering patient care coordination and health education. Support  the development of outreach and care coordination protocols, oversee productivity, and provide  clinical consultation and expertise to Wellness support staff.  

∙ Serve as a primary clinical point of contact for Providers and care teams on patient care issues  pertaining to asthma, hypertension, and other chronic disease management areas. 

∙ Maintain availability across three primary care sites to receive warm handoffs and referrals from  Providers; respond to spontaneous requests for assistance, patient education, and case management.  

∙ Continuously attend trainings, conferences, and professional development activities; maintain  familiarity and compliance with trends, best practices, recommendations, and requirements  produced by Centers for Disease Control and Prevention, Massachusetts Department of Public  Health, regulatory agencies, funders, and subject matter experts.  

∙ Support departmental leadership (e.g., grant teams, quality improvement teams) with improvement activities (e.g., data collection, presentations) related to chronic disease  management.

Working Conditions: 

∙ Position requires prolonged periods of sitting at a desk and typing on a computer; ability to stand  for prolonged periods of time; ability to perform moderate activities such as climbing stairs,  bending, stooping, reaching, and lifting up to 20 pounds at times; potential exposure to adverse  outdoor environmental conditions; and potential exposure to adverse indoor environmental  conditions, bloodborne pathogens, and chemical hazards.


JOB CODE: 10