RN Nurse Care Coordinator

Who We Are: Central City Health (CCH) has been serving the under-housed and at-risk population in metro Detroit since 1972, by providing integrated healthcare services. Our services include primary and pediatric care, dental care, behavioral and SUD care, supportive housing, and community re-entry services, to name a few. In 2024, our President/CEO, Dr. Kimberly Farrow-Felton received the esteemed Healthcare Hero Award from Crain’s Detroit Business honoring her exceptional contributions to the health and well-being of our community. Our Mission: To achieve wellness in the community by providing an array of primary and behavioral health care, housing, and substance abuse services with dignity and respect. Our Core Values: CCH is guided by a set of values in fulfilling our mission. Some of our values include: An environment that supports health and recovery. Person centered principles in the delivery of care. An environment characterized by cultural sensitivity, integrity, teamwork and trust. A commitment to service excellence and continuous quality improvement. Persons served take both an active part in their treatment and the organization. An atmosphere of welcoming and accessibility to people seeking our services that assures “no wrong door”. GENERAL DESCRIPTION: Under the guidance of the Nursing Director, the Nurse Care Coordinator serves as the primary clinical point of coordination for an assigned panel of adult members, providing continuous oversight between scheduled visits. Utilizing nursing judgment and a proactive, registry-driven approach, this role monitors for changes in members’ clinical and social needs, performs medication reconciliation and clinical triage, and facilitates timely intervention and care coordination across primary care, behavioral health, substance use disorder, pharmacy, dental, and case management services. The Nurse Care Coordinator promotes continuity of care by maintaining clinical oversight of the member’s needs and ensuring appropriate coordination and follow-through across service lines. RESPONSIBILITIES: Own a panel of every CCV-eligible adult member at the assigned site continuously — standing panel ownership, not triggered by a single visit. Proactively monitor the EHR for qualifying events between scheduled visits (per ISQ Workflow §1.2.1: new psychotropic medication, ED/inpatient visit, pregnancy, housing loss, and others), rather than relying on the event being caught at the next encounter. Perform medication reconciliation and clinical follow-up after a qualifying event, coordinating with a Pharmacist consult for complex cases. Triage Comprehensive Care Visit (CCV) and Integrated Screening Questionnaire (ISQ) findings that need escalation before the member's next scheduled contact, coordinating directly with the Physical Health Provider and BH Clinician. Apply explicit, criteria-based hand-off triggers: route to Case Manager for LOCUS Level of Care 3+, SMI/SED/I-DD determination, active SUD/MAT treatment, or ACT enrollment; route to Pharmacist for new psychotropic medication or dose change; route to Dental Provider for active dental infection (same-day) or routine referral. Own case-selection for monthly multi-disciplinary rounds, applying clinical criteria for which members are presented — resolving the Integrated Care Playbook's previously unfinished open item on this process. Serve as the clinical point of contact for the panel between CCVs — a role no current position holds for the adult, CCV-eligible population. All other duties as assigned by leader and/or senior leadership. EDUCATION AND EXPERIENCE: Active, unrestricted Michigan RN licensure. BLS certified required. Strong clinical triage judgment, including medication reconciliation competency. Minimum 2–3 years clinical nursing experience; ambulatory care, primary care, or care coordination experience strongly preferred. Experience with EHR-based registry or panel management, and comfort with proactive (not solely visit-based) patient outreach. Scope-of-practice note: the specific boundary of what this role may independently triage or assess versus what requires provider sign-off is a regulatory/clinical question, not a design preference, and must be reviewed and confirmed by CCH clinical and compliance leadership before this role is finalized or posted. SKILLS: Understanding of the dynamics of individuals who have a history of homelessness, substance abuse issues, and mental illness. Ability to clarify assignments, establish priorities and communicate effectively; ability to plan, direct, coach, motivate and evaluate the work of others. Demonstrated willingness to assume accountability, make decisions, supervise, coach, teach, counsel, and motivate others. Mastery of communication and team building skills necessary to lead meetings and make formal presentations; mastery of writing skills required for grants, proposals, and reports; as well as management of complex dynamics. Ability to analyze the impact of Managed Care environment on the Programs and apply concepts to program operations. Ability to speak and write effectively using proper grammar and punctuation. Aptitude to manage multiple responsibilities efficiently within a broad scope of functional areas. Ability to influence others in an advisory/consultative/supervisory capacity. PHYSICAL DEMANDS/WORKING CONDITIONS: Walking, sitting, and/or standing for prolong periods of time may be required. Normal office and medical office environments with exposure to noise, dust, or extreme temperatures. Must be available to work all hours scheduled. These include but are not limited to early mornings, evenings and weekend hours as determined by the organization and Senior Leadership. Work hours may shift depending on project or program needs. May have close contact with clients and/or their living environments which could include potential exposure to contagious diseases, unpleasant odors and/or to bug/pest infestations. Must possess and maintain an acceptable background check clearance, certifications, licensures and/or training as required by Central City Health, federal/state/county agencies, and other entities. This is an outline of the primary responsibilities of this position. As with everything in life, things change. The tasks and responsibilities can be changed, added to, removed, amended, deleted, and modified at any time by the organization. CCH is an Equal Opportunity Employer committed to a culturally diverse workforce. We are committed to providing an inclusive environment based on mutual respect for all candidates and team members. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, height, weight, marital status, gender identity expression, disability status, protected veteran, or other legally protected status by state or federal law. At CCH the health and safety of our employees is our top priority. Vaccination has been proven to play a critical role in combating COVID-19. As a result, CCH prefers that employees are fully vaccinated against COVID-19; however, it is not required. Expected hours: 40.0 per week. Benefits: Dental insurance. Employee assistance program. Flexible spending account. Health insurance. Health savings account. Life insurance. Paid time off. Vision insurance. People with a criminal record are encouraged to apply. Education: Bachelor's (Required). License/Certification: BLS (Required). RN License (Required). Work Location: In person.