- Manages a caseload of high-risk patients, providing complex care coordination, including referrals to specialists, transition care management, complex medication management and communication across care team members. May require occasional travel to agency's sites in Baltimore County and West Baltimore.
- Assesses and addresses the physical, functional, social, psychological, environmental, learning, and financial needs of patients.
- Develops and reviews registries regularly and coordinates with external and internal providers regarding health management to inform and support care plans. Works collaboratively with care teams to review and reduce re-admissions and avoidable admissions and ED visits. Follows up with prioritized and high-risk clients following an ED visit or hospital admission.
- Delivers health education and counseling, drawing upon the individual's strengths and motivation, to explore lifestyle choices, preferences, and safety concerns.
- Performs clinical tasks as appropriate based on license and training.
- Complete documentation within client's electronic health record in a manner that is easy to understand and in accordance with established formats and required timeframes. Ensure appropriate coding as required under Comprehensive Primary Care Functions of Advanced Primary Care.
- Involves the client in the development and implementation of an integrated treatment plan using SMART goals.
- Role model and mentor other nurses within the agency, to assess and address the physical, functional, social, psychological, environmental, learning, and financial needs of patients.
- Explores and utilizes external resources that could serve to benefit high-risk clients in meeting their needs
- Leads education groups that can foster and promote the well-being and positive health outcomes of clients
- Models and reinforces the Health Care for the Homeless "core values" of dignity, authenticity, hope, justice, passion and balance
- Actively participates in performance improvement activities and actively participates in advocacy activities that support the mission of Health Care for the Homeless
- Performs other duties on an as-needed basis
- Protects our client's personal health information by maintaining compliance with HIPAA and other relevant Health Care related IT security regulations
- Bachelor's Degree from an approved School of Nursing or Master's in Social Work
- Licensed in Maryland as a Registered Nurse or Licensed Clinical Social Worker (LCSW-C), strongly preferred
- Personal vehicle and valid Maryland driver's license
- Two years of clinical nursing/social work experience required.
- Two years of case management/care coordination experience strongly preferred (can be concurrent with clinical experience).
- Experience working with individuals experiencing homelessness and/or behavioral health disorders preferred.
- Able to work well with clients from diverse backgrounds
- Possess strong verbal and written communication skills
- Willingness to integrate principles into practice such as Harm Reduction, Motivational Interviewing and Housing First
- Strong organizational and time management skills
- Able to cope with interruptions and be a team player
- Flexible approach, working with several cross-disciplinary teams in a collaborative style
- Approaches change with a positive, open-minded attitude
- Able to work with ill, disabled, emotionally upset, and sometimes hostile clients
-
CTO Care Coordinator
1 week ago
MedStar Health Baltimore, United StatesGeneral Summary of Position · MedStar Health is looking for a CTO Care Coordinatorto join ourteam at MedStar Accountable Care, LLC · The CTO Care Coordinatorserves as a member of the Quality team capable of supporting an array of care coordination administrative processes and ser ...
-
Community Care Coordinator
4 days ago
Facility GRACE MEDICAL CENTER Baltimore, United States Full timeSummary · JOB SUMMARY: · The primary responsibility of the Community Care Coordinator working under the oversight of assigned Community Care Manager or Supervisor is to promote the health and welfare of assigned patients through face to face and/or phone outreach and e-mail com ...
-
RN Care Coordinator
1 week ago
Facility GRACE MEDICAL CENTER Baltimore, United States Full timeSummary · JOB SUMMARY: · Manages individualized patient centered goal directed Nursing Care through use of the Nursing Process and the principles of Primary Nursing in accordance with Departmental and hospital policies and procedures. Provides care coordination/management for p ...
-
Patient Care Coordinator
2 days ago
Maryland ENT Baltimore, United States Full timePATIENT CARE COORDINATOR · Positive and pleasant individual who demonstrates adaptability and is willing and able to adjust to multiple demands, shifting priorities. The Patient Care Coordinator will be located at our Johnston Professional Building practice, no travel required. T ...
-
Client Care Coordinator
3 weeks ago
Excellent Healthcare & PRP Services Baltimore, United StatesTitle: Office Coordinator/ SupportDepartment: AdministrativeDirect Report: Programs Administrator/Program DirectorSupervises: NoneSalary Range: Dependent on ExperiencePosition Purpose/SummaryThe goal of Excellent Healthcare Services is to help create mental stability, physical we ...
-
Community Care Coordinator
6 days ago
LifeBridge Health Baltimore, United StatesCommunity Care Coordinator - Grace Medical Center · Baltimore, MD · GRACE MEDICAL CENTER · FAM H&W CENTER · Full-time - Day shift - 8:30am-5:00pm · Allied Health · 83356 · Posted: · May · 8, 2024 · Apply Now · // Setting the Saved Jobs link · function setsavedjobs(externalidlist) ...
-
Patient Care Coordinator
3 days ago
Kennedy Krieger Institute Baltimore, United StatesOverview: · Kennedy Krieger Institute leads the way in translating scientific advances into new therapies and educational interventions, while providing an inspirational environment for training tomorrows leaders in the field. These successes benefit millions of children, adolesc ...
-
Home Care Coordinator RN
2 weeks ago
Edenbridge Health Baltimore, United StatesRole: Home Care Coordinator, RN · Organization: Edenbridge PACE at West Baltimore · Location: West Baltimore · Start Date: May 2024 · Status: Full-time · Mission: To allow frail elderly people to age in the location of their choosing and continue to lead · connected, meaningful l ...
-
Community Care Coordinator
1 week ago
LifeBridge Health Baltimore, United States Full timeCommunity Care Coordinator - Grace Medical Center · Baltimore, MD · GRACE MEDICAL CENTER · FAM H&W CENTER · Full-time - Day shift - 8:30am-5:00pm · Allied Health · 83356 · Posted: · May 8, 2024 · Apply Now · Save Job · Saved · Summary · JOB SUMMARY: · The primary responsibility ...
-
Patient Care Coordinator
1 week ago
Kennedy Krieger Institute Baltimore, United StatesOverview · Kennedy Krieger Institute leads the way in translating scientific advances into new therapies and educational interventions, while providing an inspirational environment for training tomorrow's leaders in the field. These successes benefit millions of children, adolesc ...
-
Patient Care Coordinator
23 hours ago
ENT Partners Baltimore, United StatesPATIENT CARE COORDINATORPositive and pleasant individual who demonstrates adaptability and is willing and able to adjust to multiple demands, shifting priorities. The Patient Care Coordinator will be located at our Johnston Professional Building practice, no travel required. This ...
-
Home Care Coordinator
2 weeks ago
Edenbridge Health Baltimore, United StatesJob Description · Job DescriptionRole: Home Care Coordinator, RN · Organization: Edenbridge PACE at West Baltimore · Location: West Baltimore · Start Date: June 2024 · Status: Full-time · Mission: To allow frail elderly people to age in the location of their choosing and continu ...
-
Patient Care Coordinator
2 days ago
Maryland ENT Baltimore, United StatesJob Description · Job Description · PATIENT CARE COORDINATOR · Positive and pleasant individual who demonstrates adaptability and is willing and able to adjust to multiple demands, shifting priorities. The Patient Care Coordinator will be located at our Johnston Professional Buil ...
-
Home Care Coordinator Assistant
1 week ago
Johns Hopkins Medicine Baltimore, United StatesJohns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strength of our service. Intrastaff is unique because it's one of the ...
-
Care Coordinator
1 week ago
Wraparound Maryland Halethorpe, United StatesJob Description · Job DescriptionSalary: Salary is $42,000.00 annually · **This position will serve our communites in Baltimore County · Overview: · Wraparound Maryland is a non-profit mental health services company focusing on our mission to provide all individuals with the mean ...
-
Remote Patient Care Coordinator
2 days ago
A2Z PHYSICAL THERAPY LLC Baltimore, United StatesBenefits: · Competitive salary · Opportunity for advancement · Paid time off · Benefits/Perks · Competitive Compensation · Careers Advancement · Paid Vacation · Job Summary · We are seeking a remote Patient Care Coordinator to join our team. In this role, you will collect, manage ...
-
Care Management Coordinator I
3 weeks ago
CareFirst BlueCross BlueShield Baltimore, United StatesSupports Care Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to care coordination and quality of care. This position will support our Medicaid Care Management team. We are looking for an exp Management, Coordinator, Cust ...
-
Care Management Coordinator I
4 days ago
Carefirst Bluecross Blueshield Baltimore, United StatesSupports Care Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to care coordination and quality of care. This position will support our Medicaid Care Management team. We are looking for an exp Management, Coordinator, Cust ...
-
Registered Nurse Care Coordinator
3 weeks ago
Department of Veterans Affairs Baltimore, Maryland, United StatesRegistered Nurse Care Coordinator - Acute Pain Services Expansion Program · Summary · This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance ...
-
Registered Nurse Care Coordinator
1 week ago
Veterans Health Administration Baltimore, United StatesSummary · This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appoi ...
Nurse Care Coordinator - Baltimore, United States - Healthcare For the Homeless Inc
Description
Job Description
Job Description**NO CALLS PLEASE**
Overview
The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing, harm reduction and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients in achieving health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to staff on best practices in care coordination. This position works with the Maryland Primary Care Program serving qualified Medicare beneficiaries.
Key Role Responsibilities
Key Agency Responsibilities
In addition to role responsibilities, each staff member of Health Care for the Homeless has the following responsibilities as a part of their employment:
Knowledge, Experience and Skills
Formal Education and Training
Experience
Skills
Health Care for the Homeless is an equal opportunity employer and is committed to racial equity and inclusion. We make a particular effort to recruit and promote Black, Indigenous and People of Color (BIPOC) for open positions. BIPOC, LGBTQIA+ individuals, people with disabilities, and people with other marginalized identities are encouraged to apply.