RN Nurse Care Coordinator

Central City Health•Detroit, MI

5d•Onsite

About The Position

Under the guidance of the Nursing Director, the Nurse Care Coordinator serves as the primary clinical point of coordination for an assigned panel of adult members, providing continuous oversight between scheduled visits. Utilizing nursing judgment and a proactive, registry-driven approach, this role monitors for changes in members’ clinical and social needs, performs medication reconciliation and clinical triage, and facilitates timely intervention and care coordination across primary care, behavioral health, substance use disorder, pharmacy, dental, and case management services. The Nurse Care Coordinator promotes continuity of care by maintaining clinical oversight of the member’s needs and ensuring appropriate coordination and follow-through across service lines.

Requirements

Active, unrestricted Michigan RN licensure.
BLS certified required.
Strong clinical triage judgment, including medication reconciliation competency.
Minimum 2–3 years clinical nursing experience; ambulatory care, primary care, or care coordination experience strongly preferred.
Experience with EHR-based registry or panel management, and comfort with proactive (not solely visit-based) patient outreach.
Bachelor's (Required).
BLS (Required).
RN License (Required).

Nice To Haves

Understanding of the dynamics of individuals who have a history of homelessness, substance abuse issues, and mental illness.
Ability to clarify assignments, establish priorities and communicate effectively; ability to plan, direct, coach, motivate and evaluate the work of others.
Demonstrated willingness to assume accountability, make decisions, supervise, coach, teach, counsel, and motivate others.
Mastery of communication and team building skills necessary to lead meetings and make formal presentations; mastery of writing skills required for grants, proposals, and reports; as well as management of complex dynamics.
Ability to analyze the impact of Managed Care environment on the Programs and apply concepts to program operations.
Ability to speak and write effectively using proper grammar and punctuation.
Aptitude to manage multiple responsibilities efficiently within a broad scope of functional areas.
Ability to influence others in an advisory/consultative/supervisory capacity.

Responsibilities

Own a panel of every CCV-eligible adult member at the assigned site continuously — standing panel ownership, not triggered by a single visit.
Proactively monitor the EHR for qualifying events between scheduled visits (per ISQ Workflow §1.2.1: new psychotropic medication, ED/inpatient visit, pregnancy, housing loss, and others), rather than relying on the event being caught at the next encounter.
Perform medication reconciliation and clinical follow-up after a qualifying event, coordinating with a Pharmacist consult for complex cases.
Triage Comprehensive Care Visit (CCV) and Integrated Screening Questionnaire (ISQ) findings that need escalation before the member's next scheduled contact, coordinating directly with the Physical Health Provider and BH Clinician.
Apply explicit, criteria-based hand-off triggers: route to Case Manager for LOCUS Level of Care 3+, SMI/SED/I-DD determination, active SUD/MAT treatment, or ACT enrollment; route to Pharmacist for new psychotropic medication or dose change; route to Dental Provider for active dental infection (same-day) or routine referral.
Own case-selection for monthly multi-disciplinary rounds, applying clinical criteria for which members are presented — resolving the Integrated Care Playbook's previously unfinished open item on this process.
Serve as the clinical point of contact for the panel between CCVs — a role no current position holds for the adult, CCV-eligible population.
All other duties as assigned by leader and/or senior leadership.