Assessment Nurse Care Coordinator (Hybrid/Remote)

Who We Are: Since 1985, BHCHP’s mission has been to provide or assure access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. We care for over 11,000 homeless individuals each year and ensure that every one of these individuals can receive comprehensive health care, which includes primary care, behavioral health, medical respite, dental, case management, and more. Our staff work in 30+ locations across the city to serve some of our community's most vulnerable—and most resilient—citizens. From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity, centering trust, mutual respect, hope, and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down physical and systemic barriers that our patients face and provide community-based health care services that are compassionate, dignified, and culturally appropriate. Job Summary: ***NOW OFFERING A $4,000 SIGN ON BONUS*** Hours: Monday - Friday 8:30am-5pm (This position will be hybrid, in-person work is expected in combination with remote work. The schedule will be determined by the Program Manager) Union: No Union Name: N/A Patient Facing: Yes BHCHP is seeking an RN who is interested in flexible weekday hours and working on a small, tight-knit team that provides care coordination services to clients enrolled in the BHCHP OneCare Program. The OneCare program is a state initiative to promote care coordination, continuity of care, and improved health outcomes for those clients under 65 who are eligible for both Medicare and Medicaid. In this role, you will mostly focus on performing Uniform Core Assessment (UCA) assessments and creating care plans customized to meet the needs of individual clients. UCA training is provided by Commonwealth Care Alliance (CCA)/CareSource. You will also help update these plans both annually and when a client has had a significant change in status. You will be required to conduct face-to-face outreach to meet with clients, assess their status, and support the client’s progress toward better health outcomes. You will also connect with clients by phone, communicate with providers about client needs, and connect clients to eligible services including visiting nursing, nutrition, durable medical equipment, and social services. BHCHP’s mission is to provide or assure access to the highest quality health care for all homeless men, women, and children in the greater Boston area. Clients may be housed; living in shelters or on the streets and this RN will need to be resourceful to connect with our clients. It is anticipated that success with connecting with clients will require communication with BHCHP care teams and shelter partners, use of BHCHP and CCA/CareSource electronic medical records, as well as outreach to clients who are living on the street, shelter, or in temporary or permanent housing. Responsibilities: Conducts UCA assessments for clients enrolled in the OneCare program. Collaboratively participates as a member of the primary care team that includes M.D.s, N.P. /P.A. s, Clinical RNs, behavioral Health Clinicians, Medical Assistants, Case Managers and others. Communicates with clients and/or caregivers including performing outreach as necessary in the greater Boston area for face-to- face contact to homes, hospitals, other facilities, etc. as needed to assess build relationships, client status, and identify new care needs. Uses CCA/CareSource and BHCHP’s Electronic Medical Records (EMR) in a timely manner to note all client interactions and outcomes accurately and efficiently. Communicates clearly and professionally with other members of the interdisciplinary team as well as with clients and caregivers. Input authorizations for Durable Medical Equipment and other services (Home Health Aide, Skilled Nursing, Physical Therapy, and Personal Care Attendant) based on UCA assessment. Bills for UCA assessments into BHCHP’s EMR (EPIC) weekly. Supports the team with transitions of care as needed. Conforms to BHCHP standards of performance around client rights, customer service, infection control, safety procedures and culturally competent care. Remains flexible in duties as role expands and is available for assistance with other projects as needed. Qualifications: Basic Knowledge/Skills: Strong medical and surgical assessment skills. Interest in working with disadvantaged groups. Understanding of substance abuse and mental health. Excellent organizational and interpersonal skills. Experience with documenting in EMR is strongly preferred. Ability to work as part of a team and autonomously. Timely and strong communication skills via phone, e-mail, and internal secured messaging systems. Ability to prioritize and have attention to timetables to complete tasks. Experience with documenting in EMRs: EPIC, Guiding Care, and ECW strongly preferred. Must be able to work with and cooperate with multidisciplinary teams to achieve best patient care. Proficient with Microsoft Office Suite and ability to adapt to technological changes. Must be well organized, efficient and can work autonomously and within a team. Driver’s license a plus. Education and Experience: Licensed as RN in Commonwealth of Massachusetts. Previous community health center or primary care experience. 1- 2 years RN experience preferred. Demonstrated interest in public health, primary and preventive nursing and working with an under-served population. Compensation and Benefits: ***NOW OFFERING A $4,000 SIGN ON BONUS*** The compensation increases based on years of experience and ranges from $40.00 - $58.00 hourly. BHCHP full-time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part-time employees. Does this amazing opportunity interest you? Then we'd love to hear from you. As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law. Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to. Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.