HEART Registered Nurse Clinical Coordinator

Swinomish Indian Tribal Community•La Conner, WA

3d•$42 - $51

About The Position

The RN Clinical Coordinator provides professional nursing assessment, clinical coordination, and care-planning support for the H.E.A.R.T. Homes program. The position promotes safe aging in place by supporting residents, caregivers, and the interdisciplinary care team through health assessment, care coordination, clinical consultation, caregiver education, monitoring changes in health status, individualized care planning, risk identification, and transition planning. The coordinator serves as a clinical resource to H.E.A.R.T. Homes staff and caregivers and helps ensure resident health and safety needs are identified, communicated, and addressed in a timely manner. The role works collaboratively with residents, families, caregivers, healthcare providers, community partners, and other professionals involved in residents’ care. It does not replace or assume the responsibilities of a primary care provider, home health agency, skilled nursing service, hospice provider, or other treating healthcare professional. Services are limited to clinical coordination, consultation, assessment, and oversight within the RN’s professional scope, applicable Washington State requirements, and H.E.A.R.T. Homes program policies and scope. The position is administratively supervised by the H.E.A.R.T. Homes Program Manager and maintains professional nursing accountability within the RN’s scope of practice and applicable laws, regulations, and professional standards. The RN has direct access to the Health Services Director or designated clinical authority for clinical concerns, resident safety concerns, professional practice matters, complex clinical situations, or issues requiring escalation beyond the Program Manager’s authority.

Requirements

Current, active, and unrestricted Registered Nurse (RN) license in Washington State.
Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited nursing program.
Demonstrated knowledge of chronic disease management, fall prevention, medication safety, aging-related health concerns, and health risk identification.
Demonstrated clinical assessment and care coordination skills.
Strong communication, documentation, organization, and interpersonal skills.
Knowledge of professional nursing principles, practices, standards, and ethics; nursing assessment, care planning, coordination, and health-status monitoring; geriatric health and common chronic conditions; functional decline, cognitive changes, and injury prevention; medication safety; infection prevention; emergency response; community-based services; care transitions; person-centered care; applicable nursing laws and standards; confidentiality; and mandatory reporting obligations.
Ability to communicate complex health information clearly; recognize changes in condition and determine when escalation or further evaluation is warranted; develop and monitor health-related care recommendations; maintain confidentiality; and build effective working relationships with residents, families, caregivers, providers, and interdisciplinary team members.
Ability to work independently while recognizing when consultation or clinical escalation is necessary; exercise sound judgment within RN scope; remain effective during urgent or changing situations; collaborate with an interdisciplinary team; prioritize work with limited direct supervision; adapt to changing needs and community-based environments; and maintain reliable attendance and established work schedules.
Ability to use electronic health records, care management systems, Microsoft Office applications, email, and other technology required for the position.
Ability to travel between resident homes, program locations, healthcare facilities, and community settings as required.
Commitment to respectful, person-centered care and support for Elders and their families.
Commitment to Swinomish cultural values and respectful engagement with the Swinomish community.
Current, unrestricted Washington State RN license; valid Washington State Driver’s License; and current CPR/BLS certification or ability to obtain it within the organization’s established timeframe.
Additional certifications, licenses, or training may be required depending on program responsibilities, organizational policies, funding requirements, or applicable laws and regulations.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Experience in geriatric nursing, community health, home health, public health, case management, care coordination, or a related area preferred.
Experience working within an interdisciplinary care team preferred.
Experience working with Tribal Health programs, Native American communities, or culturally specific healthcare programs preferred.
Knowledge of culturally responsive and respectful approaches to working with Native American/Tribal communities and Elders preferred.

Responsibilities

Participate in initial resident assessments and enrollment-related clinical reviews; conduct nursing assessments within the RN’s scope and program responsibilities; and review available medical, nursing, medication, functional, and health histories.
Assess functional abilities, ADLs and IADLs as applicable; evaluate fall, injury, environmental, and other health and safety risks; identify changes in physical, cognitive, behavioral, emotional, or functional status; and recognize conditions or symptoms that may warrant further evaluation or intervention.
Recommend or coordinate follow-up with healthcare providers when indicated, document assessments and follow-up accurately and promptly, and maintain appropriate boundaries between nursing assessment and medical diagnosis or treatment.
Provide nursing input into individualized service and care plans by identifying health-related needs, goals, risks, strengths, and barriers; recommending supports within program scope; reviewing plans after significant changes; participating in quarterly, annual, and other required reassessments; and communicating recommendations to the care team.
Review reports of resident health or functional changes; monitor trends in falls, injuries, emergency visits, hospitalizations, functional changes, and other significant events; determine when assessment, provider notification, monitoring, or escalation is needed; and document actions taken.
Provide health-related education and consultation to caregivers, including education about resident-specific conditions, care needs, safety, reporting changes, fall and infection prevention, emergency response, and care-plan implementation.
Participate in caregiver competency assessment or evaluation when appropriate; promote respectful, person-centered care; and communicate caregiver concerns, limitations, or training needs that may affect resident safety to program leadership.
Coordinate authorized communication with primary care providers, specialists, home health and hospice providers, therapists, pharmacies, hospitals, and other healthcare professionals; support discharge planning, appointments, referrals, follow-up, case conferences, and continuity of information across care settings.
Participate in review and follow-up of falls, injuries, medication-related concerns, and other incidents; identify preventable risks and recommend safety interventions; participate in emergency planning, quality improvement, and reporting of suspected abuse, neglect, exploitation, or other reportable concerns as required.
Identify when resident needs may exceed H.E.A.R.T. Homes’ scope or resources; conduct or coordinate reassessments; recommend additional services or medical evaluation; participate in planning transitions to higher levels of care or alternative living arrangements; and support continuity and communication during transitions.
Maintain complete, accurate, timely, confidential clinical records and protect resident health information; practice within professional scope, competence, and authority; seek consultation and escalate concerns appropriately; and participate in required meetings, training, continuing education, and competency activities.
Perform other related duties as assigned within the scope of the position and professional licensure.
Travel between resident homes, program locations, healthcare facilities, and community settings as required.