RN Case Manager chez Healthcare For the Homeless

RN Case Manager, Mobile Integrated Care

Reports To: Manager of Integrated Care

Location: Field-Based Settings (streets, encampments, community sites)

Overview
The Nurse Case Manager for the Mobile Integrated Care Team serves alongside the Associate Medical Director as the operational and clinical lead for a multidisciplinary outreach program designed to engage individuals experiencing unsheltered homelessness with complex behavioral health and medical needs. This role coordinates daily team operations, facilitates partner alignment, and ensures high-quality service delivery in the field. The Nurse Case Manager provides on-the-ground leadership during client encounters, supports crisis response, and ensures that program activities meet grant deliverables, quality standards, and client needs. While not a formal supervisor, the Program Manager functions as the central point of accountability for coordinating staff efforts and integrating medical, behavioral health, and outreach services in real time.

Duties and Responsibilities
Program Leadership & Coordination

• Lead daily operations of the Mobile Integrated Care Team, coordinating activities among HHH staff, The Harris Center, CFTH, and Houston Recovery Center partners.
• Serve as the field-based point of accountability for program implementation, ensuring fidelity to model design, trauma-informed practices, and harm reduction approaches.
• Coordinate logistics, staffing coverage, supply ordering, and daily outreach deployment to high-need areas, including encampments, transit hubs, and community hotspots.
• Facilitate communication and alignment among team members in the field, reinforcing shared care plans and consistent engagement strategies.
• Participate and lead regular case consultations and multidisciplinary team meetings to review complex cases, resolve barriers, and refine approaches.

Client Engagement & Field Leadership

• Provide direct engagement during field encounters, supporting crisis stabilization, care coordination, and warm handoffs to housing, behavioral health, and medical services.
• Act as the on-the-ground clinical leader, guiding team response in high-acuity situations and ensuring appropriate escalation pathways (including compelled care when necessary and legally appropriate).
• Build trust-based relationships with clients who have historically been resistant to traditional healthcare, sustaining engagement through consistent street-level interactions.
• Promote client-centered strategies that prioritize safety, autonomy, and long-term stability.
• Complete necessary patient assistance program and other relevant clinical applications.

Partner Integration & Systems Navigation

• Coordinate team activities with hospitals, sobering centers, EMS, and law enforcement to provide alternatives to ER visits or jail.
• Ensure program activities align with CoC standards, HMIS documentation requirements, and partner expectations.
• Act as liaison between frontline staff and system partners, ensuring information flow and integration across agencies.
• Strengthen partnerships to expand referral pipelines and improve care transitions for high-barrier individuals.

Compliance & Quality Improvement

• Ensure documentation is completed accurately in EPIC and HMIS, meeting CoC and FQHC standards.
• Monitor performance metrics tied to program outcomes, including engagement, diversion, and stabilization indicators.
• Support quality improvement initiatives, identifying gaps in service delivery and recommending enhancements.
• Assist in preparing reports for internal leadership, grant funders, and partner agencies.

Support HHH Mission

• Demonstrates a commitment to HHH’s mission of promoting health, hope, and dignity for individuals experiencing homelessness through equitable and compassionate care.
• Upholds trauma-informed, culturally responsive, and patient-centered principles in all interactions, contributing to an inclusive and supportive environment for patients and team members.
• Actively contributes to a culture of collaboration, accountability, and innovation in service of our goal to eliminate health disparities and advance systems-level change.

Minimum Qualifications 

• Current RN license in the State of Texas, in good standing
• Associate or bachelor’s degree in nursing from an accredited program
• At least 3–5 years of experience managing or coordinating community-based, outreach, or mobile health programs
• Experience working with individuals experiencing homelessness, behavioral health conditions, or complex medical needs
• Familiarity with harm reduction, motivational interviewing, and trauma-informed care models
• Proficiency in EHR systems (EPIC preferred) and clinical documentation
• Strong communication, organizational, and critical thinking skills
• Comfortable working in field-based, non-traditional care environments

Preferred Qualifications 

• Masters degree in Nursing, Social Work, Public Health, or related field
• Prior experience in street medicine, crisis response, or homeless healthcare delivery
• Experience in a Federally Qualified Health Center (FQHC) or outreach setting
• Bilingual in English and Spanish 
• HHH values lived experience as an essential form of expertise. Individuals who have experienced homelessness, housing instability, or other barriers to healthcare access are strongly encouraged to apply.