HEART Registered Nurse Clinical Coordinator

The RN Clinical Coordinator provides professional nursing assessment, clinical coordination, and care-planning support for the H.E.A.R.T. Homes program. The position promotes safe aging in place by supporting residents, caregivers, and the interdisciplinary care team through health assessment, care coordination, clinical consultation, caregiver education, monitoring of changes in health status, individualized care planning, risk identification, and transition planning.

The RN Clinical Coordinator serves as a clinical resource to H.E.A.R.T. Homes staff and caregivers and helps ensure that resident health and safety needs are identified, communicated, and addressed in a timely manner. The position works collaboratively with residents, families, caregivers, healthcare providers, community partners, and other professionals involved in the resident’s care.

The RN Clinical Coordinator does not replace or assume the responsibilities of a resident’s primary care provider, home health agency, skilled nursing service, hospice provider, or other treating healthcare professional. The position provides clinical coordination, consultation, assessment, and oversight only within the RN’s professional scope of practice, applicable Washington State requirements, and the defined scope and policies of the H.E.A.R.T. Homes program.

The RN Clinical Coordinator is administratively supervised by the H.E.A.R.T. Homes Program Manager and maintains professional nursing accountability within the RN’s scope of practice and applicable laws, regulations, and professional standards.

The RN Clinical Coordinator has direct access to the Health Services Director or designated clinical authority for clinical concerns, resident safety concerns, professional practice matters, complex clinical situations, or circumstances in which clinical judgment requires escalation beyond the Program Manager’s authority.

• Participate in initial resident assessments and enrollment-related clinical reviews.
• Conduct nursing assessments within the RN’s scope of practice and program responsibilities.
• Review available medical, nursing, medication, functional, and health histories.
• Assess functional abilities and activities of daily living (ADLs) and instrumental activities of daily living (IADLs), as applicable.
• Evaluate fall, injury, environmental, and other health and safety risks.
• Identify changes in physical, cognitive, behavioral, emotional, or functional status.
• Identify health conditions or changes that may affect a resident’s ability to safely participate in H.E.A.R.T. Homes services.
• Recognize signs and symptoms that may warrant additional medical evaluation or intervention.
• Recommend or coordinate appropriate follow-up with healthcare providers when indicated.
• Document assessments, findings, recommendations, and follow-up activities accurately and timely.
• Maintain appropriate boundaries regarding nursing assessment, clinical consultation, and medical diagnosis or treatment.

• Provide nursing input into individualized service and care plans.
• Identify health-related needs, goals, risks, strengths, and potential barriers to safe aging in place.
• Recommend appropriate nursing and caregiver supports within the program’s scope.
• Review care plans following significant changes in health, function, cognition, living circumstances, or caregiver capacity.
• Participate in quarterly, annual, and other required reassessments.
• Recommend modifications to caregiver supports, services, monitoring, or safety interventions when clinically appropriate.
• Ensure health-related recommendations are communicated to…