This RN role focuses on in-person care coordination for people experiencing homelessness who are enrolled in a Medicaid/Medicare alignment program. The clinician performs Uniform Core Assessments, develops and updates individualized care plans, and helps connect clients to services such as home health, nursing, nutrition, durable medical equipment, and social supports. Work includes face-to-face outreach across the community, coordination with interdisciplinary teams, and documentation in multiple electronic records systems.
Key Responsibilities
- Conduct Uniform Core Assessments for clients enrolled in the OneCare program.
- Develop and update individualized care plans based on assessment findings and changes in client status.
- Perform face-to-face outreach to clients in homes, shelters, hospitals, and other community settings.
- Communicate with providers, caregivers, and interdisciplinary team members about client needs and progress.
- Document client interactions, outcomes, and care activities in BHCHP and CCA/CareSource electronic medical records.
- Input authorizations for durable medical equipment and other covered services.
- Support transitions of care and connect clients to eligible community and clinical services.
- Coordinate care with primary care, behavioral health, case management, and shelter partners.
Required
- Active RN license in Massachusetts.
- Strong medical and surgical assessment skills.
- Ability to work collaboratively with multidisciplinary teams.
- Ability to communicate effectively with clients, caregivers, and team members.
Preferred
- 1-2 years of RN experience.
- Previous community health center or primary care experience.
- Experience documenting in an EMR.
- Experience with EPIC, Guiding Care, or ECW.
- Interest in public health, preventive nursing, and underserved populations.
- Driver's license.
Benefits & Perks
- $4,000 sign-on bonus.
- Monday-Friday schedule with flexible weekday hours.
- Mostly in-person work with some remote hours possible.
- Training provided for Uniform Core Assessments.
- Opportunity to work on a small, tight-knit care coordination team.
- Access to BHCHP and CCA/CareSource electronic medical records.