RN Nurse Care Coordinator

Central City Health•Detroit, MI

19d•Onsite

About The Position

The RN Nurse Care Coordinator serves as the primary clinical point of coordination for an assigned panel of adult members, providing continuous oversight between scheduled visits. Under the guidance of the Nursing Director, the coordinator uses nursing judgment and a proactive, registry-driven approach to monitor changes in members’ clinical and social needs, perform medication reconciliation and clinical triage, and coordinate timely interventions across primary care, behavioral health, substance use disorder, pharmacy, dental, and case management services. The role promotes continuity of care by maintaining clinical oversight and ensuring appropriate coordination and follow-through across service lines. Central City Health provides integrated healthcare services to under-housed and at-risk populations in metro Detroit. Its services include primary and pediatric care, dental care, behavioral and substance use disorder care, supportive housing, and community re-entry services. Its mission is to promote community wellness through primary and behavioral healthcare, housing, and substance abuse services delivered with dignity and respect. The position is expected to work 40 hours per week in person. Work hours may shift with project or program needs and may include early mornings, evenings, and weekends. The role may involve close contact with clients or their living environments and possible exposure to contagious diseases, unpleasant odors, pests, noise, dust, or extreme temperatures. CCH prefers employees to be fully vaccinated against COVID-19, but vaccination is not required.

Requirements

Active, unrestricted Michigan RN licensure.
BLS certification.
Minimum 2–3 years of clinical nursing experience.
Strong clinical triage judgment, including medication reconciliation competency.
Bachelor’s degree required.
Ability to understand the dynamics of individuals with histories 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; assume accountability; make decisions; supervise, teach, counsel, and motivate others.
Communication and team-building skills to lead meetings and make formal presentations, along with writing skills for grants, proposals, and reports and the ability to manage complex dynamics.
Ability to analyze the impact of the Managed Care environment on programs and apply concepts to program operations.
Ability to speak and write effectively using proper grammar and punctuation.
Ability to manage multiple responsibilities efficiently across a broad range of functional areas.
Ability to influence others in an advisory, consultative, or supervisory capacity.
Must be available to work all scheduled hours, which may include early mornings, evenings, and weekends.
Must maintain acceptable background check clearance, certifications, licensures, and training as required by CCH and relevant agencies.

Nice To Haves

Ambulatory care, primary care, or care coordination experience.
Experience with EHR-based registry or panel management.
Comfort with proactive patient outreach rather than solely visit-based care.

Responsibilities

Continuously own a panel of every CCV-eligible adult member at the assigned site, providing standing panel oversight rather than coordination triggered only by a single visit.
Proactively monitor the EHR for qualifying events between scheduled visits, including new psychotropic medication, emergency department or inpatient visits, pregnancy, and housing loss.
Perform medication reconciliation and clinical follow-up after qualifying events, coordinating pharmacist consultation for complex cases.
Triage Comprehensive Care Visit (CCV) and Integrated Screening Questionnaire (ISQ) findings that require escalation before the member’s next scheduled contact, coordinating directly with the Physical Health Provider and BH Clinician.
Apply criteria-based hand-off triggers: refer to a Case Manager for LOCUS Level of Care 3+, SMI/SED/I-DD determination, active SUD/MAT treatment, or ACT enrollment; refer to a Pharmacist for a new psychotropic medication or dose change; and refer to a Dental Provider for active dental infection or routine dental referral.
Own case selection for monthly multidisciplinary rounds and apply clinical criteria to determine which members are presented.
Serve as the clinical point of contact for the panel between CCVs.
Perform other duties as assigned by the leader and/or senior leadership.