Care Coordinator - RN

HAVEN FOR HOPE OF BEXAR COUNTY • San Antonio, TX

9d • $80,000 - $100,000

About The Position

The Care Coordinator provides direct nursing care, clinical assessment, care coordination, health education, and clinical support to people experiencing homelessness through Haven for Hope’s Medical Respite Program and Learning Clinic. As a central member of the interdisciplinary healthcare team, the position supports continuity of care for clients with acute and chronic medical conditions. The Care Coordinator works with medical providers, hospitals, pharmacies, behavioral health professionals, case managers, and community healthcare partners to promote timely, coordinated, compassionate, trauma-informed, and evidence-based care.

The role provides nursing services and coordinates transitions of care, follow-up appointments, referrals, medication needs, hospital discharges, and other healthcare services. It helps identify barriers to care and works with clients and the interdisciplinary team to improve health outcomes, promote client independence, and reduce avoidable emergency department visits and hospital admissions.

The Care Coordinator also serves as an Adjunct Faculty member with St. Mary’s University School of Nursing, supporting nursing students through clinical instruction, mentorship, supervision, and experiential learning at Haven for Hope.

Requirements

• Registered Nurse (RN) license in the State of Texas.
• Master of Science in Nursing (MSN) from an accredited nursing program.
• Current BLS certification.
• Minimum of two years of professional nursing experience.
• Knowledge of professional nursing principles, practices, and standards.
• Strong clinical assessment and critical-thinking skills.
• Ability to coordinate care across multiple healthcare providers and systems.
• Ability to recognize changes in health status and appropriately escalate care.
• Ability to establish rapport with clients from diverse backgrounds.
• Ability to work effectively in a fast-paced and dynamic environment.
• Commitment to trauma-informed, person-centered, and low-barrier care.
• Ability to mentor and support nursing students and emerging healthcare professionals.
• Ability to manage multiple clients with complex medical and social needs.
• Strong interpersonal, communication, organizational, and documentation skills.
• Ability to work effectively as part of an interdisciplinary team.
• Proficiency with electronic medical records and standard computer applications.
• Valid Texas driver’s license, acceptable driving record, reliable transportation, and required automobile insurance for any vehicle used in performing job duties.

Nice To Haves

• Experience in medical respite, community health, primary care, homeless healthcare, behavioral health, or another safety-net healthcare setting.
• Experience with care coordination, case management, transitions of care, or hospital discharge planning.
• Experience with wound care, chronic disease management, and medication management.
• Previous experience as a clinical instructor, nursing preceptor, or adjunct faculty member.
• Experience working with individuals experiencing serious mental illness, substance use disorders, or complex medical conditions.
• Experience or demonstrated ability to work with individuals experiencing homelessness or other vulnerable populations.

Responsibilities

• Coordinate healthcare services for clients with complex medical, behavioral health, and social needs.
• Facilitate communication among Haven for Hope, hospitals, primary care and specialty providers, pharmacies, and community healthcare partners.
• Support hospital discharge planning and arrange appropriate follow-up care.
• Coordinate referrals, appointments, laboratory testing, specialty care, and other recommended healthcare services.
• Monitor client follow-up and help address barriers to accessing healthcare.
• Conduct medication reconciliation and coordinate medication access and continuity.
• Participate in interdisciplinary care conferences and case reviews.
• Develop and support individualized care plans with clients and the interdisciplinary team.
• Coordinate transitions between the Medical Respite Program, Learning Clinic, hospitals, and community-based healthcare providers.
• Identify clients at increased risk of hospitalization, medical deterioration, or gaps in care and coordinate interventions.
• Help clients navigate healthcare systems and understand treatment plans.
• Collaborate with case managers and other Haven for Hope staff to address social determinants of health affecting medical outcomes.
• Provide direct nursing care in the Medical Respite Program and Learning Clinic.
• Conduct nursing assessments and monitor changes in clients’ health status.
• Obtain and document vital signs, health histories, medication information, and other clinical information.
• Administer medications and treatments within the RN scope of practice and organizational protocols.
• Provide wound care, chronic disease monitoring, post-hospitalization support, and other appropriate nursing interventions.
• Perform clinical triage, help determine the appropriate level of care, recognize changes in condition, and escalate care appropriately.
• Support medical providers during examinations, procedures, and clinical visits.
• Assist with point-of-care testing, specimen collection, injections, and other nursing procedures within the RN scope of practice.
• Educate clients about diagnoses, medications, treatment plans, chronic disease management, preventive care, and follow-up recommendations.
• Ensure timely and accurate documentation of clinical services.
• Serve as an Adjunct Faculty member with St. Mary’s University School of Nursing.
• Provide clinical instruction, supervision, mentorship, and guidance to nursing students during clinical experiences at Haven for Hope.
• Facilitate hands-on learning in community-based healthcare, medical respite, integrated care, and services for people experiencing homelessness.
• Supervise and evaluate student clinical performance in accordance with university and nursing program requirements.
• Provide constructive feedback and coaching to support student learning and professional development.
• Collaborate with university faculty to coordinate student placements, learning objectives, clinical experiences, and evaluations.
• Educate students about how homelessness, behavioral health, substance use, chronic illness, and social determinants of health affect healthcare outcomes.
• Model professional nursing practice, ethical decision-making, trauma-informed care, cultural humility, and person-centered care.
• Maintain client confidentiality and ensure student compliance with HIPAA, professional standards, and Haven for Hope policies.
• Support the partnership between Haven for Hope and St. Mary’s University to strengthen nursing education and community-based healthcare.

Benefits

• Reimbursement for approved and documented business-related travel and other authorized work expenses in accordance with company policy.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level