Assessment Nurse Care Coordinator (Hybrid/Remote)

Boston Health Care for the Homeless Program • Boston, MA

1d • $40 - $58 • Hybrid

About The Position

Boston Health Care for the Homeless Program (BHCHP) is seeking a registered nurse to provide care coordination for clients enrolled in its OneCare Program, a state initiative supporting care coordination, continuity of care, and improved health outcomes for people under 65 who are eligible for Medicare and Medicaid. The role primarily conducts Uniform Core Assessments (UCAs) and develops individualized care plans. UCA training is provided by Commonwealth Care Alliance (CCA)/CareSource. The nurse updates care plans annually and when clients experience significant changes in status, conducts face-to-face outreach, assesses client needs, and supports progress toward improved health outcomes.

The nurse connects with clients by phone and in person, communicates client needs to providers, and helps connect clients to eligible services such as visiting nursing, nutrition, durable medical equipment, and social services. Clients may be housed, staying in shelters, or living on the streets, so the role requires resourcefulness and outreach across the greater Boston area. Success relies on communication with BHCHP care teams and shelter partners and use of BHCHP and CCA/CareSource electronic medical records. The position is hybrid, combining in-person and remote work, with the schedule determined by the Program Manager. Hours are Monday through Friday, 8:30 a.m. to 5:00 p.m. The role is patient-facing and non-union, and offers a $4,000 sign-on bonus.

Requirements

• Must be licensed as a registered nurse in the Commonwealth of Massachusetts.
• Strong medical and surgical assessment skills.
• Previous community health center or primary care experience.
• Strong organizational and interpersonal skills.
• Ability to work both as part of a team and autonomously.
• Timely, strong communication skills by phone, email, and internal secured messaging systems.
• Ability to prioritize, meet timetables, and complete tasks with attention to detail.
• Ability to cooperate with multidisciplinary teams to achieve the best patient care.
• Proficiency with Microsoft Office Suite and ability to adapt to technological changes.
• Interest in working with disadvantaged groups and an understanding of substance abuse and mental health.
• Demonstrated interest in public health, primary and preventive nursing, and serving an underserved population.

Nice To Haves

• One to two years of registered nurse experience preferred.
• Experience documenting in electronic medical records, particularly EPIC, Guiding Care, and ECW, is strongly preferred.
• A driver’s license is a plus.

Responsibilities

• Conduct Uniform Core Assessments (UCAs) for clients enrolled in the OneCare Program.
• Participate collaboratively as a member of the primary care team, including physicians, nurse practitioners and physician assistants, clinical registered nurses, behavioral health clinicians, medical assistants, case managers, and other team members.
• Communicate with clients and/or caregivers and conduct outreach, including face-to-face visits in the greater Boston area to homes, hospitals, and other facilities as needed, to build relationships, assess client status, and identify new care needs.
• Use CCA/CareSource and BHCHP electronic medical records to document client interactions and outcomes accurately, efficiently, and in a timely manner.
• Communicate clearly and professionally with interdisciplinary team members, clients, and caregivers.
• Enter authorizations for durable medical equipment and services such as home health aides, skilled nursing, physical therapy, and personal care attendants based on UCA assessments.
• Bill for UCA assessments in BHCHP’s EPIC electronic medical record weekly.
• Support the team with transitions of care as needed.
• Follow BHCHP standards for client rights, customer service, infection control, safety procedures, and culturally competent care.
• Remain flexible as duties expand and assist with other projects as needed.

Benefits

• $4,000 sign-on bonus.
• Compensation of $40.00–$58.00 per hour, with increases based on years of experience.
• Competitive time-off program for full-time employees.
• Health, dental, and vision insurance for full-time employees.
• 403(b) retirement savings plan for full-time employees.
• Pre-tax MBTA pass program with a 40% discount.
• Additional compensation for demonstrated bilingual proficiency.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed