Lead RN Care Coordinator (4 days a week) 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.
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 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.
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.
Manages a caseload of high-risk patients with chronic conditions, providing complex case management.
Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients.
Works collaboratively with care teams to maximize quality of life as well as reduce avoidable admissions, re-admissions and ED visits.
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.
Knowledge, Experience And Skills Possess current licensure as a Registered Nurse in Maryland.
Bachelor’s in nursing preferred; associates in nursing required plus 5 years of relevant work experience may be substituted.
Possess current BLS CPR.
Personal vehicle and valid Maryland driver’s license.
Experience Two years of clinical nursing.
Two years of case management experience preferred (can be concurrent with clinical experience).
Experience working with individuals who have behavioral health disorders preferred.
Supervisory experience 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.
Key Agency Responsibilities Models and reinforces the agency 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.
Performs other duties on an as-needed basis.
Protects clients’ personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations.
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.
Health Care for the Homeless is an equal opportunity employer and welcomes applications from diverse candidates.