RN Community Outreach Care Coordinator

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Full Time Minneapolis, MN, US

Salary Range: $39.49 To $49.79 Annually

SUMMARY:

The Float RN provides direct clinical care and patient care coordination for culturally-diverse populations in the medical clinic as well as in the community alongside the Harm Reduction Team. This role is primarily responsible for providing flexible coverage for a variety of clinic nursing roles as needed , possibly including mobile nursing, infectious disease, maternal-child health, and primary care. The role will consistently serve people experiencing barriers to healthcare , including homelessness and substance use , by emphasiz ing trauma-informed care and harm reduction principles .

Through strong collaboration with an interdisciplinary team, the Float RN is a key team member in support ing patient continuity of care .

DUTIES AND RESPONSIBILITIES:

• Professional Clinical Care and Clinic/Outreach-Based Care Coordination
• This position will flex between clinical programs and provide back-up nursing care. Care delivery may include:
• Deliver skilled interventions including, but not limited to, wound care and assessment, foot care, medication and vaccine administration, phlebotomy, education, standing orders, minor procedures if appropriate, and vital signs.
• Conduct nurse-led or provider-level visits through the utilization of standing orders.
• Coordinate and assist in provider visits via telehealth, in the community, or at the clinic site.
• Utilize harm reduction strategies to address health concerns disproportionately affecting unhoused populations including HIV, hepatitis C, STIs, wounds, foot health, asthma, diabetes, substance use disorder, overdose risk, and behavioral health concerns. Provide harm reduction services including naloxone trainings , syringe and safer use supplies, and harm reduction education.
• Coordinate care for prenatal, perinatal, postpartum, newborn, infant and pediatric patients.
• Facilitate rapid access to OB care, HIV and hepatitis C care, PrEP , PEP, and MOUD for substance use disorder.
• Provide professional clinical care (including triage, assessment, intervention, evaluation) in varying community settings, as well as in the fixed-site clinic, prioritizing trauma-informed care principles and patient-led care plans.
• Perform assessments of patients’ unmet medical, behavioral, and social care needs and support the care team in meeting these needs. Help patients navigate community resources and specialty care, as well as linkages to primary care when needed. Work to reduce barriers through follow-up, transportation support, appointment reminders, and other strategies. Provide advocacy on behalf of patients seeking outside care.
• Work collaboratively with clinic staff to identify high-risk or out-of-care individuals. Offer mobile care coordination services and linkages to care as appropriate.
• Complete accurate, timely documentation of patient encounters in the electronic medical record according to clinic protocol.
• Read and interpret patient charts and lab results. Review new labs and identify need for follow up. Communicate with other clinical providers as needed.
• Assist patients in care transitions, such as entering or discharging from treatment, hospitalizations, respite programs, and shelters. Work with external service providers to ensure continuity of care.
• Support care plan and medication adherence through medication set up, delivery, and routine lab draws .
• Perform clinical exams in clinic and outreach environments.
• Program Implementation
• In collaboration with other Outreach, Medical, and Harm Reduction staff,…