RN Coordinator Home Visiting Program

Greater Lawrence Family Health Center•Lawrence, MA

9h•$38 - $44•Hybrid

About The Position

Under the direction of the Site Nurse Manager, the RN Coordinator provides comprehensive care management and coordination for medically complex, homebound, and high-risk patients who require skilled assessment and care planning follow-up. In this hybrid role, the RN provides longitudinal patient support, clinical triage, transitions of care, and coordination across multiple care settings. The RN works closely with providers, specialists, visiting nurse agencies (VNA), durable medical equipment (DME) vendors, and a Community Health Worker (CHW) to promote continuity of care and help prevent unnecessary hospitalization.

Requirements

Active Registered Nurse (RN) license in good standing required.
Bilingual Spanish required.
Experience managing medically complex or high-risk patients.
Strong clinical triage skills and comfort with remote patient management.
Familiarity with DME, VNA services, and care coordination workflows.
Strong clinical judgment, communication, and organizational skills.
Comfortable utilizing telehealth platforms and electronic health records.
Ability to manage complex and multifaceted patient needs.
Strong care coordination skills and ability to collaborate effectively within a team-based care model.
Commitment to patient-centered and equitable care.

Nice To Haves

Experience in primary care, home care, geriatrics, or care management preferred.

Responsibilities

Provide longitudinal care management for a panel of medically complex patients.
Conduct telephonic and/or virtual assessments, triage patient concerns, and determine the appropriate level of care.
Support chronic disease management and monitor for changes in clinical status.
Reinforce care plans, medication adherence, and patient/caregiver education.
Perform timely post-discharge outreach following hospital or facility stays.
Reconcile medications, review discharge instructions, and identify gaps in care.
Coordinate follow-up appointments and services in collaboration with providers and the Care Navigator.
Escalate clinical concerns identified during transitions-of-care outreach.
Coordinate care across specialists, VNA services, DME vendors, and community-based organizations.
Facilitate referrals and ensure completion of specialty care and diagnostic services.
Participate in interdisciplinary team meetings and case conferences.
Perform occasional planned, non-urgent home visits for vaccinations or scheduled clinical needs.
Assess the home environment for safety and barriers to care when indicated.
Maintain accurate and timely documentation in the electronic health record (EHR).
Support quality initiatives, preventive care outreach, and high-risk patient tracking.
Utilize registries and reporting tools for panel management.
Provide patient and caregiver education tailored to literacy level and cultural context.
Support patients in navigating social determinants of health and accessing community resources.