Registered Nurse - Transitional Care

Colorado Coalition for the Homeless•Denver, CO

17h•$37 - $40•Hybrid

About The Position

The Registered Nurse plays a critical role in delivering high-quality, compassionate healthcare to homeless and at-risk individuals. This position requires clinical expertise within an integrated, trauma-informed care model, focusing on the complex health needs of a diverse patient population. The RN is essential in promoting patient-centered care and improving overall well-being through adaptability, resilience, and a proactive approach to overcoming healthcare barriers. The Transitional Care Management RN works collaboratively within the Integrated Health Care for the Homeless team. The RN in this position is responsible for coordinating health care transitions for patients of The Colorado Coalition for the Homeless (CCH). The RN will work collaboratively with partner hospitals to improve patient outcomes with hospital discharges and improve access to hospital follow up visits at CCH. This RN will assess patient needs and goals and assist in connecting patient to the correct resources. The RN is responsible performing both independent and delegated duties in the provision of providing comprehensive health care to all patients. The RN is responsible for providing nursing and triage support to the CCH Respite team and on-site nursing support at Stout Street Health Center (SSHC) and affiliated satellite clinics, as needed.

Requirements

Associate’s, Bachelor’s or Master’s degree in Nursing from an accredited college or university.
Current Registered Nurse licensure in the State of Colorado.
Basic Life Support certification.

Nice To Haves

Preferred experience in ambulatory, public, community, mental health, or emergency nursing.
Familiarity with diverse or marginalized communities is highly desirable.
Bilingual preferred

Responsibilities

Provide skilled nursing care according to community standards and CCH protocols.
Deliver comprehensive patient-centered care, addressing physical, emotional, and social needs.
Conduct rapid and accurate triage assessments, providing appropriate care recommendations.
Educate patients on managing chronic and acute health conditions.
Administer medications safely and effectively as per protocols.
Collaborate closely with a multidisciplinary healthcare team to ensure holistic patient care.
Facilitate access to internal programs such as health outreach and housing support services.
Oversee care for patients with transitional, chronic, and complex health conditions.
Mentor new nurses and nursing students, enhancing their clinical skills and confidence.
Document all patient interactions and care activities in the electronic health record (EHR).
Engage in continuous professional development and participate in quality improvement initiatives.
Provides patient-centered care within an integrated, trauma-informed, culturally-aware, harm-reduction model
Ability to perform quick and accurate triage assessments with appropriate recommendations of care as outlined in SSHC nursing protocols via telephone or in-person
Empowers patients by providing appropriate health education and information, including but not limited to addressing common chronic and acute health conditions in this population, such as diabetes management, hypertension management, nutrition, wound care, infectious disease, gender affirming care, family planning including parenting, adoption and abortion, and disease prevention.
Collaborates with other members of the multi-disciplinary health care team and coordinates care with internal programs.
As a member of an OBH licensed Substance Use Disorder (SUD) treatment team, provides treatment services such as case management, crisis services, initial intake program screenings, individual medication assisted treatment (MAT) counseling, and administering scales to assess withdrawal.
Provide nursing services as needed to all CCH programs and facilities.
Preceptor to new nurses and nursing students
Participates in team-based or interdisciplinary quality improvement initiatives
Attends required disciplinary, inter-disciplinary, suite, quality improvement, and all-staff meetings
Ability to work day, evening or weekend clinic as scheduled or appropriate.
Ensure timely, accurate documentation of all clinical services, communications, and patient records in the EHR.
Monitor EHR inboxes for CCH patients who have experienced and Emergency Room or hospital admission and assist them with PCP follow up planning.
Assist with medical case management of patients with high ED utilization, with the goal of reducing hospital admissions through robust primary care.
Performs other duties as assigned.