Lead Registered Nurse Care Coordinator

Health Care for the Homeless-posted 3 months ago

Full-time • Mid Level

Baltimore, MD

101-250 employees

Religious, Grantmaking, Civic, Professional, and Similar Organizations

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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).

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.
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.
Reviews and utilizes available data (e.g. CRISP) to identify improvement opportunities and address health-related needs for individuals.
Identifies and prioritizes funding uses for HEART and other available resources to qualifying clients.

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.
Two years of clinical nursing experience.
Two years of case management experience preferred.
Experience working with individuals who have behavioral health disorders preferred.
Supervisory experience preferred.

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.

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.

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