Lead Registered Nurse Care Coordinator presso Health Care for the Homeless

Overview 

The Lead RN Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Lead Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Lead collects and analyzes patient-level data, assists with development and maintenance of care plans, and evaluates outcomes of interventions. This role will supervise other members of the MDPCP Care Team, including the Care coordinator(s). 

What You'll Do

• Trains and coaches’ staff, sets clear expectations, monitors outcomes, creates a culture of open communication and helps team members solve complex problems through individual supervision and team meetings. Fosters a collaborative, supportive and collegial environment across departments.
• Manages a caseload of high-risk patients with chronic conditions, providing complex case management. This may include referrals to chronic disease case management, supporting transitions of care, high risk clinical tracking, and ensuring access to complex medication management.

• Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients. Involves the client in the development and implementation of an integrated treatment plan.
• Works collaboratively with care teams to maximize quality of life as well as reduce avoidable admissions, re-admissions and ED visits. Follows up with MDPCP clients following an ED visit or hospital admission. Helps the Agency monitor and reach out to other health center clients in need of ED or hospital follow-up.
• Delivers health education and counseling, drawing upon the individual’s strengths and motivation to explore lifestyle choices, preferences, and safety concerns. 
• Perform clinical tasks as appropriate based on license and training including health education groups. 
• Completes clear and timely documentation within electronic health record in a manner that is consistent with MDPCP and agency standards.
• Oversees AHEAD model’s (e.g. MDPCP) day-to-day operations to ensure success of the program including:

Leads and organizes MDPCP-related events including patient and family advisory council, Completing risk stratification as required to identify clients deemed “high-risk” and in need of care coordination services. Leads and organizes outreach plan to high-risk individuals, Providing expertise to care management functions across the agency including additional populations identified for needing care management services regardless of payer source, Reviewing  

• Reviews and utilizes available data (e.g. CRISP) to identify improvement opportunities and address health-related needs for individuals 
• Identifies and prioritizes funding uses for HEART and other available resources to qualifying clients

Knowledge, Experience and Skills  

Formal Education and Training 

• Possess current licensure as a Registered Nurse in Maryland
• Bachelor’s in nursing preferred; associates in nursing required plus 5 years of relevant work experience may be substituted 
• Possess current BLS CPR 
• Personal vehicle and valid Maryland driver’s license

Experience  

• Two years of clinical nursing
• Two years of case management experience preferred (can be concurrent with clinical experience)
• Experience working with individuals who have behavioral health disorders preferred
• Supervisory experience preferred 

Skills  

• Able to work well with clients from diverse backgrounds
• Possess strong verbal and written communication skills
• Willingness to integrate principles into practice such as Harm Reduction, Motivational Interviewing and Housing First

• Strong organizational and time management skills
• Able to cope with interruptions and be a team player
• Flexible approach, working with several cross-disciplinary teams in a collaborative style
• Approaches change with a positive, open-minded attitude
• Able to work with ill, disabled, emotionally upset, and sometimes hostile clients

Key Agency Responsibilities  

In addition to role responsibilities, each staff member of Health Care for the Homeless has the following responsibilities as a part of their employment: 

• Models and reinforces the agency core values of dignity, authenticity, hope, justice, passion and balance
• Actively participates in performance improvement activities and actively participates in advocacy activities that support the mission 
• Performs other duties on an as-needed basis
• Protects clients’ personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations

Why Join Us?

• Be part of a mission-driven team committed to racial equity, social justice, and community wellness.

• Work in a dynamic, people-first organization that centers compassion, authenticity, and hope.

• Receive training and support to grow in your advocacy and peer work.

• Help shape the future of housing and recovery services in Baltimore.

Read more about our clients and the people we serve here: https://www.hchmd.org/who-we-help

Join us in advancing health equity and delivering exceptional care to our community’s most underserved populations. Apply today to be a part of something bigger.

Health Care for the Homeless is an equal opportunity employer.

Notice to Applicants
Health Care for the Homeless participates in E-Verify. All newly hired employees are required to complete the I-9 Employment Eligibility Verification form and provide documentation proving their identity and legal authorization to work in the United States.

We use the E-Verify system to confirm employment eligibility in accordance with federal law.