The objective of the Nurse Care Coordinator is to improve health care outcomes. Under the supervision of the Social Services Supervisor and in conjunction with the HIV multi-disciplinary team, the Nurse Care Coordinator is responsible for providing psychosocial, medical case management, care coordination and clinical services. The position will facilitate care transitions between external care facilities (i.e. Emergency Department, hospital, home health, rehabilitation facilities, etc) and MNHC. Make home visits to provide nursing care to high medical acuity patients and those with comorbidities. Back up Clìnica nurse as needed.

Essential Functions/Responsibilities:

Care Coordination – Approximately 35% Time

Provide a range of client-centered activities focused on improving health outcomes in support of clients being retained in care and achieving HIV viral suppression. Activities may be prescribed by the multi-disciplinary team. Medical Care Coordination includes all types of Care Coordination encounters (e.g., face-to-face, phone contact, and any other forms of communication). Key activities include:

• Initial assessment of service needs -- Provide initial and follow-up Psychosocial Assessments which include obtaining a psychosocial history and current situation, sexual history, relevant medical history, substance abuse history, mental status exam and a needs assessment for concrete services such as financial benefits, housing, transportation and other social services.
• Development of a comprehensive, individualized care plan -- Develop a treatment plan and implement the plan through the provision of interventions (counseling, education), coordination with multi-disciplinary team and /or through facilitated referrals.
• Timely and coordinated access to medically appropriate levels of health and support services and continuity of care
• Continuous client monitoring to assess the efficacy of the care plan -- Provide direct support services to clients through one-on-one contacts and groups at MNHC HIV Clinic, home visits, and hospital visits. Assist clients in identifying barriers to services and help them access needed services.
• Re-evaluation of the care plan at least every 6 months with adaptations as necessary
• Provide individual counseling and risk-reduction to clients and significant other as appropriate.
• Ongoing assessment of the client’s and other key family members’ needs and personal support systems
• Treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments
• Intensive outreach to patients who are not on HIV treatment with continuous follow up plan with attention to reengagement in care
• Client-specific advocacy and/or review of utilization of services -- Empower/educate clients to make informed decisions regarding health care and use of social services system.
• Accompany clients to appointments as needed and assist with ensuring that clients receive language appropriate services when indicated.
• Work with “hard to reach populations” to facilitate the access of HIV positive individuals to early intervention, primary care and other support services.
• Must be readily available to enroll clients in emergency ADAP
• Medical Care Coordination may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medi-Cal, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services and insurance plans through the health insurance Marketplaces/Exchanges – Covered California)

Care Management – Approximately 35% Time

• Conduct outreach to eligible and referred patients for care management, via phone or in-person.
• Participate in Care Conferences with patient, family members as needed and patient’s Care Team.
• Interface with other Departments in co-managing patients and participate in inter-departmental projects.
• Develop patient-centered, individualized Care Plans for our most medically vulnerable clients:
  • Assess clients for ability to attend all medical appointments including primary care visits, procedures, imaging and specialty visits.
  • Actively address barriers to attending medical appointments.
  • Support client in attending all medical appointments. This may include collaborating with other agencies, arranging transport, phone call reminders or arranging for the patient to be accompanied to the visit.
  • Provide regular medication reconciliation with clients. Assess adherence and develop continuous follow up plan for medication non-adherence.
  • Provide meaningful telephone follow up after hospitalizations and link patients to appropriate medical follow up care.
  • Assess clients for the need of a home visit, and provide home visits as needed to those that would benefit.
  • Support identification of patient’s strengths and barriers to ensure optimal and successful Care Plans. Respect patient health choices in the Care Plan process.
  • Track barriers to care, assist with eliminating or reducing barriers to obtaining needed services.
  • Collaborate with patient to navigate the system of providers and social service agencies.
  • Support Nurse, patient and caregiver(s) in re-assessment of Care Plan goals.
  • Connect patient to cultural, community, housing and social resources, and follow-up to assure connections are made whenever possible
• Act as a liaison to hospitals, long-term care settings, specialists, home health representatives, and other community agencies in collaboration with Nurse.
• Facilitate care transitions for patients discharging from external facilities (i.e. skilled nursing, hospital, and emergency room) and ensure appropriate follow-up with patient’s PCP in a timely manner.

Clinical Duties – Approximately 10% Time

• Provides medical treatment as ordered and performs procedures according to MNHC Nursing Protocols. 
• Prepares and administers medications as ordered.
• Cover nursing duties of the HIV clinic such as medication renewals when the nurse is sick, on vacation or attending continuing education courses. 

Administrative Duties – Approximately 20% Time

• Attend weekly multi-disciplinary team meetings and present clients’ psychosocial assessment and treatment plan based on recommendations from physician, health educator, nutritionist, and other team members. Participate in staff meetings and in-service training. Participates in and attends nursing staff meetings. Receive weekly individual clinical supervision.
• Attends and actively participate in Care Management/Health Homes Team meetings, Care Team Huddles, and assigned meetings and/or trainings.
• Provides input and shares creative strategies to improve the Care Management/Health Homes Program.
• Completes all required documentation in a timely fashion in accordance with regulations, funder requirements, program standards and workflows.
• Documentation of interventions in clients’ records.
• Make community presentations of HIV Services.
• Other duties as assigned.

Qualifications:

• Current California licensure as a Registered Nurse or Licensed Vocation Nurse
• Bachelor’s degree in Nursing, Social Work, Public Health or related field
• 2 years’ experience in outpatient/ambulatory nursing
• 2 years’ experience in case management/care coordination
• Bilingual (Spanish/English) required.
• One-year experience in working with HIV/AIDS clients.
• Experience with substance abuse and the Latino community preferred.
• Sensitivity to HIV/AIDS and Gay, Lesbian, Bisexual, and Transgender issues
• Ability to work professionally and ethically within multi-cultural settings, including ability to maintain confidentiality and privacy of persons, documents, data, and communications.

To learn more about our organization, please visit our website at www.mnhc.org. We offer a full range of benefits which includes the following:

• Medical Insurance – MNHC pays 90-100% based on plan
• Dental and Vision Insurance – free to employee
• Life Insurance – free basic policy plus voluntary option
• Flexible Spending Accounts for health & dependent care expenses
• Commuter benefits for public transportation expenses
• Vacation – 2 weeks (3 weeks after 5 yrs; 4 weeks after 8 yrs)
• 12 Paid Holidays plus your birthday and 12 Sick Days each year
• 40 hours Paid Educational Leave
• 401k Retirement Savings Plan with Company Contribution

Mission Neighborhood Health Center is an Equal Employment Opportunity employer committed to fostering an inclusive environment for our diverse workforce. We do not discriminate based upon race, religion, color, national origin, sex (including pregnancy, childbirth, reproductive health decisions, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, genetic information, or other applicable legally protected characteristics. Pursuant to the San Francisco Fair Chance Ordinance, we will consider employment for qualified applicants with arrest and conviction records.