Shelter Outreach Care Management - RN

Hunter Health•Wichita, KS

6d•Onsite

About The Position

The Shelter Outreach Care Management – RN provides scheduled on-site nursing outreach at Second Light and other designated community locations and supports Hunter Health’s Care Management program when not assigned to shelter coverage. The role assesses health needs, delivers nursing services within an RN scope of practice, coordinates care across Hunter Health Clinic services and community partners, and helps patients establish ongoing care. In collaboration with the Director of Population Health, Shelter Nurse, and Care Management team, the RN helps maintain compliance with federal grants, HRSA, FTCA, HIPAA, and HHC policies and procedures. The RN provides clinical nursing services under provider standing orders, including assessments, triage, screenings, immunizations, injections, vital-sign monitoring, wound care, and patient education. The role also performs care-management functions such as transition-of-care follow-up, reviewing records, assisting patients with program enrollment and scheduling, coordinating chronic-care planning and referrals, addressing quality-care gaps, and documenting interactions in the electronic health record and value-based care platforms. The position participates in coordination and quality-improvement meetings, maintains professional knowledge, and travels to shelters and community organizations as directed.

Requirements

Current Registered Nurse (RN) license in the state of Kansas.
At least three years of clinical nursing experience.
Current Basic Life Support (BLS) certification within 30 days of hire.
Experience coordinating care across multiple healthcare and community organizations.
Ability to maintain appropriate clinical privileges.
Ability to communicate effectively with patients and respond effectively to internal and external needs.
Organizational and multitasking skills, effective time and resource management, and sound judgment and decision-making.
Ability to collaborate, seek clarification, confirm accuracy, contribute to projects, and develop positive working relationships.
Initiative, reliability, accuracy, thoroughness, and ability to manage priorities and follow work procedures.
Ability to evaluate own performance and accept constructive feedback.
Commitment to serving underserved and vulnerable populations.
Ability to meet the stated physical and sensory demands, with reasonable accommodation if needed.

Nice To Haves

Clinical experience in community health, primary care, emergency care, behavioral health, care management, case management, or homeless healthcare.
Experience facilitating chronic care management.
Bilingual abilities.

Responsibilities

Provide nursing services in accordance with HHC clinical policies and protocols and provider standing orders.
Complete nursing assessments, triage, medical screenings, and risk identification.
Administer immunizations, TB tests, and therapeutic injections as ordered.
Conduct infectious-disease and preventive-health screenings; assess vital signs and other health measures.
Perform wound assessments, cultures, and care.
Provide clinic-approved over-the-counter medications and education when clinically appropriate.
Coordinate patient care with Second Light staff and other onsite medical providers.
Coordinate post-emergency-room and hospital-discharge transition-of-care follow-up.
Review patient records from hospitals and other resources.
Assist patients with enrollment and scheduling in programs such as chronic care management, remote hypertension monitoring, transportation services, and the Prescription Assistance Program, according to program requirements.
Collaborate with providers on chronic-care case management and care planning.
Coordinate care across HHC service lines, including designated visits, social-driver-of-health programs, and outside referrals.
Provide evidence-based health education to patients as directed.
Assist care teams with identifying and closing quality-care gaps.
Document clinical interactions and attribution-based patient data in the EHR and value-based-care platforms as directed.
Participate in meetings with accountable care organizations, Second Light leadership and staff, homeless-service provider work groups, and internal HHC teams for coordination, reporting, and quality improvement.
Maintain job knowledge through educational opportunities, professional publications, personal networks, and professional organizations.
Travel to shelters and other community organizations as directed.
Perform other duties as assigned.
Maintain compliance with applicable grants, HRSA, FTCA, HIPAA, and HHC policies and procedures.