Registered Nurse - Nurse Care Coordinator – Per Diem

Do you want the chance to make a real and lasting difference in the lives of those in need? Healthcare for the Homeless is looking for a compassionate and self-motivated Registered Nurses (RN) to join our direct care team as Nurse Care Coordinators on a per-diem basis.

The Nurse Care Coordinator will ensure patients have access to care and services through the Health Care for the Homeless (HCH) program. This role will focus on addressing the complex medical and behavioral health needs of the uninsured, underinsured, those experiencing homelessness and housing insecure individuals by utilizing the nursing process to conduct comprehensive assessments and identify co-occurring medical, mental health, and substance use disorders. Additionally, the Nurse Care Coordinator will provide care for patients with substance use disorders participating in the Medication Assisted Treatment (MAT) Program. Responsibilities include care coordination, chronic disease management, counseling, and health education.

Responsibilities

• Perform triage and rapid clinical assessments for patients who present at HCH shelter-based clinics, in partnership with the HCH behavioral health team.
• Initiate appropriate emergency response in life-threatening or unusual situations to stabilize patients; promptly and directly notify the HCH provider(s).
• Assess and document patients’ vital signs, physical symptoms and chief complaints in preparation for their clinic visit.
• Perform comprehensive bio-psycho-social assessments and conduct mental health and substance use disorder (SUD) screenings using evidenced based tools.
• In collaboration with the interdisciplinary team, develop individualized care plans based upon nursing assessment as indicated. Provide health education and counseling to patients in support of self – care and health management goals.
• Based on the assessment, refer patients to the appropriate level and category of care within the multidisciplinary HCH team, and effectively communicate assessment findings and screening results to medical and behavioral health providers.
• Ensure all patients’ clinical assessments, diagnostic results and consult reports are up to date in the electronic medical record (EMR) in preparation for clinic visits with medical and behavioral health providers.
• Coordinate all aspects of care to ensure continuity of care within the HCH team and to ensure access to all required diagnostics, specialty care and services in the community.
• Coordinate discharge plans for each clinic visit; arrange referrals for diagnostic and specialty care, with support for transportation, escort, translation and medication assistance as needed.
• Perform nursing care interventions as ordered by the providers, and in support of the providers, for medication administration, point of care testing, and diagnostic procedures during each clinic session.
• As scheduling permits, participate in the Street Medicine program in collaboration with the HCH staff to identify, engage, and enroll individuals experiencing homelessness into HCH care.

MAT-Specific Patient Assessment & Care Coordination:

• In collaboration with the Behavioral Health Provider, perform initial assessments including medical and mental health, medication, substance use and social history.
• Communicate and meet with the MAT treatment team and other HCH team members on a regular basis, employing a harm reduction approach to patient care.
• Provide education to patients and the community about access to MAT treatment programs.
• Assess and closely monitor patients through the induction, stabilization and maintenance phases of treatment.
• Manage scheduled nursing visits, urine toxicology screens, initial and ongoing lab testing, patient education and medication refills, as ordered by protocol or medical provider.
• In collaboration with licensed prescribing physicians, APRNs, PAs, and pharmacists, follow State and Federal guidelines in providing care to patients with substance use disorders.
• Work with the prescriber to obtain prior authorizations as needed.

Job Requirements

• Graduate of an accredited school of nursing.
• Licensed by the state of New Hampshire as a Registered Nurse (RN) and/or compact license.
• CPR/BLS certification required.
• Basic computer keyboarding and data entry skills, required.
• Minimum of 3 years of professional nursing experience.
• Valid Driver’s License or the ability to transport self to and from off-site locations.
• Experience working with adults with substance use disorders, with case management and psychiatric experience preferred.

Equal Opportunity Employer: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, marital or familial status, age, or mental or physical handicap.

Equal Opportunity Employer
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