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 admissions.

In 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.
• Recognize changes in a client’s condition and appropriately escalate care.
• Support medical providers during examinations, procedures, and clinical visits.
• Assist with point-of-care testing, specimen collection, injections, and other nursing procedures within the RN scope of practice.
• Provide health education regarding diagnoses, medications, treatment plans, chronic disease management, preventive care, and follow-up recommendations.
• Ensure timely and accurate documentation of all clinical services.

NURSING EDUCATION & ADJUNCT FACULTY RESPONSIBILITIES

• Serve as an Adjunct Faculty member with St. Mary’s University School of Nursing.
• Provide clinical instruction, supervision, mentorship, and guidance to nursing students participating in clinical experiences at Haven for Hope.
• Facilitate hands-on learning opportunities in community-based healthcare, medical respite, integrated care, and healthcare services for individuals experiencing homelessness.
• Supervise and evaluate student clinical performance in accordance with university and nursing program requirements.
• Provide constructive feedback and coaching to support student learning and professional development.
• Collaborate with St. Mary’s University faculty to coordinate student placements, learning objectives, clinical experiences, and evaluations.
• Educate students regarding the impact of homelessness, behavioral health, substance use, chronic illness, and social determinants of health on healthcare outcomes.
• Model professional nursing practice, ethical decision-making, trauma-informed care, cultural humility, and person-centered care.
• Maintain client confidentiality and ensure student compliance with HIPAA, professional standards, and Haven for Hope policies.
• Support the ongoing partnership between Haven for Hope and St. Mary’s University to strengthen nursing education and community-based healthcare.

EDUCATION and LICENSURE

• Registered Nurse (RN) license in the State of Texas.
• Master of Science in Nursing (MSN) from an accredited nursing program required.
• Current BLS certification.
• Minimum of two years of professional nursing experience.

EXPERIENCE

• Experience in medical respite, community health, primary care, homeless healthcare, behavioral health, or another safety-net healthcare setting.
• Experience with care coordination, case management, transitions of care, or hospital discharge planning.
• Experience with wound care, chronic disease management, and medication management.
• Previous experience as a clinical instructor, nursing preceptor, or adjunct faculty member.
• Experience working with individuals experiencing serious mental illness, substance use disorders, or complex medical conditions.
• Experience or demonstrated ability to work with individuals experiencing homelessness or other vulnerable populations.

KNOWLEDGE/SKILLS/ABILITIES

• Knowledge of professional nursing principles, practices, and standards.
• Strong clinical assessment and critical-thinking skills.
• Ability to coordinate care across multiple healthcare providers and systems.
• Ability to recognize changes in health status and appropriately escalate care.
• Ability to establish rapport with clients from diverse backgrounds.
• Ability to work effectively in a fast-paced and dynamic environment.
• Strong commitment to trauma-informed, person-centered, and low-barrier care.
• Ability to mentor and support nursing students and emerging healthcare professionals.
• Strong clinical assessment, critical-thinking, and care coordination skills.
• Ability to manage multiple clients with complex medical and social needs.
• Strong interpersonal, communication, organizational, and documentation skills.
• Ability to work effectively as part of an interdisciplinary team.
• Proficiency with electronic medical records and standard computer applications

CERTIFICATES, LICENSES, REGISTRATIONS

• Must possess a valid Texas driver’s license, maintain an acceptable driving record, and have reliable transportation with the required automobile insurance coverage for any vehicle used in the performance of job duties.
• Eligible employees will be reimbursed for approved and documented business-related travel and other authorized work expenses in accordance with company policy.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Standard physical activity such as periodic standing, walking, sitting, basic motor skills to access computer files for information or simple data entry.

Travel within the city and its surrounding areas may be required (if applicable).

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.