Care Coordinator - RN

SUMMARY: The Care Coordinator provides direct nursing care, clinical assessment, care coordination, health education, and clinical support to individuals experiencing homelessness through Haven for Hope’s Medical Respite Program and Learning Clinic.

The Care Coordinator serves as a central member of the interdisciplinary healthcare team and is responsible for helping coordinate and support continuity of care for clients with acute and chronic medical conditions. This position works closely with medical providers, hospitals, pharmacies, behavioral health professionals, case managers, and community healthcare partners to ensure clients receive timely, coordinated, compassionate, trauma-informed, and evidence-based healthcare.

The Care Coordinator will provide direct nursing services within the Medical Respite Program and Learning Clinic while also coordinating transitions of care, follow-up appointments, referrals, medication needs, hospital discharges, and other healthcare services. The position will assist in identifying barriers to care and works collaboratively with clients and the interdisciplinary team to improve health outcomes, promote client independence, and reduce avoidable emergency department visits and hospital  addition to clinical and care coordination responsibilities, the Care Coordinator will serve as an Adjunct Faculty member with St.

Mary’s University School of Nursing. In this capacity, the Care Coordinator will support nursing students through clinical instruction, mentorship, supervision, and experiential learning opportunities at Haven for Hope. This will foster the development of future nursing professionals while enhancing interdisciplinary client care.

ESSENTIAL DUTIES AND RESPONSIBILITIES CARE COORDINATION RESPONSIBILITIES Coordinate healthcare services for clients with complex medical, behavioral health, and social needs.

Facilitate communication and coordination between Haven for Hope, hospitals, primary care providers, specialty providers, pharmacies, and other community healthcare partners.

Support hospital discharge planning and ensure appropriate follow-up care is arranged.

Coordinate referrals, medical appointments, laboratory testing, specialty care, and other recommended healthcare services.

Monitor client follow-up and assist in addressing barriers that may prevent clients from accessing healthcare.

Conduct medication reconciliation and coordinate medication access and continuity.

Participate in interdisciplinary care conferences and case reviews.

Develop and support individualized care plans in collaboration with clients and members of the interdisciplinary team.

Coordinate transitions between the Medical Respite Program, Learning Clinic, hospitals, and community-based healthcare providers.

Identify clients at increased risk for hospitalization, medical deterioration, or gaps in care and coordinate appropriate interventions.

Assist clients in navigating complex healthcare systems and understanding their treatment plans.

Collaborate with case managers and other Haven for Hope staff to address social determinants of health that impact medical outcomes.

MEDICAL RESPITE & CLINICAL RESPONSIBILITIES Provide direct nursing care to clients in the Medical Respite Program and Learning Clinic.

Conduct nursing assessments and monitor clients for changes in health status.

Obtain and document vital signs, health histories, medication information, and other clinical information.

Administer medications and treatments within the RN scope of practice and organizational protocols.

Provide wound care, chronic disease monitoring, post-hospitalization support, and other nursing interventions as appropriate.

Perform clinical triage and assist in determining the appropriate level of care.

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