Chronic Care & MAT RN Coordinator

Department: Clinical                                       Reports To: Director of Clinical Services

FLSA Status: Non-Exempt                                         Location: Multiple Locations             

Position Summary:

The RN Chronic Care & MAT Nurse Coordinator plays a vital role in advancing the mission of our FQHC by providing compassionate, comprehensive care to underserved populations. This dual-role position supports patients with chronic illnesses and those receiving Medication-Assisted Treatment (MAT) for substance-use disorders. The nurse also provides clinical supervision and support to Chronic Care Management (CCM) staff, ensuring high-quality, coordinated care delivery. Additionally, the RN will provide direct clinical support at the Daybreak Homeless Shelter’s Respite Center, assisting with medication management and other duties as needed. The role involves collaboration with primary care, behavioral health, and community partners to deliver integrated, culturally competent care that addresses the social determinants of health.

Key Responsibilities:

Chronic Care Management (CCM):

• Identify and engage patients with complex chronic conditions (e.g., diabetes, hypertension, asthma, CHF).
• Conduct comprehensive assessments and develop patient-centered care plans.
• Monitor clinical outcomes and coordinate follow-up care, including referrals to specialists and community resources.
• Provide health coaching and self-management education tailored to literacy and cultural needs.
• Track and report on UDS and HEDIS quality measures relevant to chronic disease management.
• Supervise and mentor CCM staff, including LPNs, care coordinators, and health coaches; provide training, performance feedback, and support in care planning and documentation.
• Track and report on enrollment, patient engagement, care gap closure, and billing metrics.
• Monitor program compliance with CMS and payer guidelines.
• Lead quality improvement initiatives related to chronic disease management and preventive care.

Medication-Assisted Treatment (MAT):

• Support MAT program operations including patient intake, education, and follow-up.
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• Conduct initial nursing assessments (vital signs, medical history, medication review, withdrawal assessment tools like COWS.
• Administer and monitor buprenorphine, naltrexone, or other MAT medications per protocol.
• Educate patients about MAT medications, safe use, side effects, and adherence.
• Conduct urine drug screens, coordinate lab testing, and document treatment progress.
• Collaborate with behavioral health providers to ensure integrated care planning.
• Assist with prior authorizations, medication access, and pharmacy coordination.
• Support patient engagement by reinforcing counseling and behavioral therapy participation.
• Coordinate referrals to behavioral health, counseling, or higher levels of care when indicated

Clinical Support at Daybreak Respite Center:

• Provide direct nursing care and medication management for patients in the respite program.
• Conduct nursing assessments and assist with chronic disease management, wound care, and coordination of follow-up services.
• Collaborate with shelter staff and FCPC clinical teams to ensure continuity of care.
• Support individuals experiencing homelessness with compassionate, trauma-informed care.
• Perform other clinical duties as needed to support the health and well-being of respite center clients.

Qualifications:

• Education: Associate or Bachelor of Science in Nursing (ASN/BSN) from an accredited program.
• Licensure: Active RN license in the state of [Insert State]; BLS certification required.
• Experience:
• At least 2 years of nursing experience in primary care, community health, or addiction treatment.
• At least one year’s experience in medication management.
• Experience working with underserved, diverse, or vulnerable populations.
• Preferred: Bilingual (English/Spanish or other language); experience with FQHCs or PCMH models.

Core Competencies:

• Leadership and team-building skills.
• Commitment to health equity and trauma-informed care.
• Strong communication and motivational interview skills.
• Ability to work effectively in a multidisciplinary, team-based environment.
• Familiarity with EHR systems (e.g., eClinicalWorks).
• Knowledge of FQHC compliance standards, including HRSA, UDS, and 340B.