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Overview

The Nurse 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, harm reduction and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients in achieving health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to staff on best practices in care coordination. This position works with the Maryland Primary Care Program serving qualified Medicare beneficiaries.

Key Role Responsibilities

• Manages a caseload of high-risk patients, providing complex care coordination, including referrals to specialists, transition care management, complex medication management and communication across care team members. May require occasional travel to agency’s sites in Baltimore County and West Baltimore.
• Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients.
• Develops and reviews registries regularly and coordinates with external and internal providers regarding health management to inform and support care plans. Works collaboratively with care teams to review and reduce re-admissions and avoidable admissions and ED visits. Follows up with prioritized and high-risk clients following an ED visit or hospital admission.
• Delivers health education and counseling, drawing upon the individual’s strengths and motivation, to explore lifestyle choices, preferences, and safety concerns. 
• Performs clinical tasks as appropriate based on license and training.
• Complete documentation within client’s electronic health record in a manner that is easy to understand and in accordance with established formats and required timeframes. Ensure appropriate coding as required under Comprehensive Primary Care Functions of Advanced Primary Care.
• Involves the client in the development and implementation of an integrated treatment plan using SMART goals.
• Role model and mentor other nurses within the agency, to assess and address the physical, functional, social, psychological, environmental, learning, and financial needs of patients.
• Explores and utilizes external resources that could serve to benefit high-risk clients in meeting their needs
• Leads education groups that can foster and promote the well-being and positive health outcomes of 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 Health Care for the Homeless “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 of Health Care for the Homeless
• Performs other duties on an as-needed basis
• Protects our client’s personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations

Knowledge, Experience and Skills 

Formal Education and Training

• Bachelor’s Degree from an approved School of Nursing or Master’s in Social Work
• Licensed in Maryland as a Registered Nurse or Licensed Clinical Social Worker (LCSW-C), strongly preferred

• Personal vehicle and valid Maryland driver’s license

Experience 

• Two years of clinical nursing/social work experience required.
• Two years of case management/care coordination experience strongly preferred (can be concurrent with clinical experience).
• Experience working with individuals experiencing homelessness and/or behavioral health disorders 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

Health Care for the Homeless is an equal opportunity employer and is committed to racial equity and inclusion. We make a particular effort to recruit and promote Black, Indigenous and People of Color (BIPOC) for open positions. BIPOC, LGBTQIA individuals, people with disabilities, and people with other marginalized identities are encouraged to apply.