Lead Registered Nurse Care Coordinator

Job Description

Job Description

Key Details

Schedule : 4 days a week, 32 hours a week.

Location : Essential, on-site role at 421 Fallsway Main Clinic

Number of Direct Reports : 1

Status : Exempt

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

Knowledge, Experience and Skills

Formal Education and Training

Experience

Skills

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 :

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 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.