Care Coordinator (RN or MSW)
Baltimore, Maryland•Full-time
$71,111 - $88,000 annually
$71,111 - $88,000 annually
About the Job
NOTE: This is a position can be part-time with 32 hours (4 8-hr days) per week or full-time at 40 hours a week.
Overview:
The 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 Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The 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:
- 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
Knowledge, Experience and Skills:
Formal Education and Training:
- 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.
Experience:
- 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.
Skills:
- 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.
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:
- 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.
Why Join Us?
- Be part of a mission-driven team committed to racial equity, social justice, and community wellness.
- Work in a dynamic, people-first organization that centers compassion, authenticity, and hope.
- Receive training and support to grow in your advocacy and peer work.
- Help shape the future of housing and recovery services in Baltimore.
Join us in advancing health equity and delivering exceptional care to our community’s most underserved populations. Apply today to be a part of something bigger.
Health Care for the Homeless is an equal opportunity employer.
Notice to Applicants:
Health Care for the Homeless participates in E-Verify. All newly hired employees are required to complete the I-9 Employment Eligibility Verification form and provide documentation proving their identity and legal authorization to work in the United States.
Health Care for the Homeless participates in E-Verify. All newly hired employees are required to complete the I-9 Employment Eligibility Verification form and provide documentation proving their identity and legal authorization to work in the United States.
We use the E-Verify system to confirm employment eligibility in accordance with federal law.
About Health Care for the Homeless
Locations:
Baltimore City – Downtown - 421 Fallsway, Baltimore, MD 21202
Baltimore City – West Baltimore - 2000 W. Baltimore St., Suite 3300 Baltimore, MD 21223
Baltimore County - 9150 Franklin Square Dr., Suite 301 Baltimore, MD 21237
Our Vision
Everyone is healthy and has a safe home in a just and respectful community.
Our Mission
We work to end homelessness through racially equitable health care, housing and advocacy in partnership with those of us who have experienced it.
Our mission: "...to prevent and end homelessness for vulnerable individuals and families by providing quality, integrated health care and promoting access to affordable housing and sustainable incomes through direct service, advocacy and community engagement."
Over 35+ years, we at Health Care for the Homeless have steadily grown and strengthened our approach to care to meet the needs of the vulnerable people we served. We are driven by a single and unwavering goal: to improve access to care for clients, and to provide them with the highest possible quality of care. Continuing in that spirit, we are now implementing a care model that takes quality and access to a new level.
A health home delivers person-centered, whole-person care that is evidence-based, uses data and listens to clients to continuously improve the care we deliver. We have been person-centered and focused on the whole person since the first client walked through our clinic doors in 1985. We’ve also always applied evidenced-based standards to our work and used data to inform our care.
What’s changed is how much we’ve grown over the years: We have more disciplines, staff members and sites. Coordinating all of our activity today requires a more powerful and standardized way of delivering care.
We are a health home.
Five areas of focus
As a health home, we apply five (5) clinical areas of focus to the care we deliver.
ACCESS FOR THOSE WHO NEED US
People should be able to reach us easily when they need help. So we ensure 24/7 access to clinical advice; make our appointment schedules and hours flexible and accommodating; and enable clients to access their health records electronically. We also are increasing our presence throughout the community. We have clinics in dowtown Baltimore, West Baltimore and Baltimore County. And we are continually expanding our street outreach and reaching more people with our mobile clinic.
TEAM-BASED CARE
Whole-person care requires the expertise of many different providers. Done well, it demands collaboration and constant communication among these providers. We are integrating our care providers into multidisciplinary care teams, each with a “panel” of clients, so they can develop care plans that span the range of treatment and services with clients.
CARE MANAGEMENT
Not only are we committed to providing clients with the best possible care; we are committed to positioning them to manage their own care. To that end, we make sure we know which client groups have the highest needs; we share clients' care plans with them and across their care teams; we provide clients with the tools to care for themselves and we make sure they are part of all decisions relating to their care; and we help them manage their medications.
BETTER MANAGE AND COORDINATE CARE
People experiencing homelessness often have complex conditions that require intensive care coordination. Our providers specialize in identifying these particularly vulnerable individuals. They provide them with the multi-disciplinary support that keeps them out of hospital emergency rooms, and they help them develop reasonable, healthy goals for themselves. This coordinated and comprehensive care includes helping individuals put a roof over their heads.
IMPROVE THE HEALTH OF THE LARGER POPULATION
As a population, people without homes have higher rates of chronic disease, such as diabetes, than their housed counterparts. We are using evidence-based guidelines to standardize and expand our assessments for these conditions. And we are continuously seeking ways to help our clients manage and treat their conditions.
________________________________________
Person-centered, whole-person care
We provide person-centered, whole-person care, combining health care services and supportive services with advocacy.
We provide whole-person care in a safe, respectful environment with acute sensitivity to clients’ life experiences. All have endured trauma; many engage in behaviors that pose a risk to their health. Through a trauma-informed and harm reduction approach, we meet individuals where they are, engage them in care with dignity and work to engage them fully in their own overall wellness.
TRAUMA-INFORMED CARE
Trauma is central to the homeless experience. People without homes often experience life trauma before they end up on the street, and living on the street is, in itself, traumatic. Trauma affects everything from our ability to trust others and build relationships to our brain development. For these reasons, we at Health Care for the Homeless are committed to providing trauma-informed care, a best practice that recognizes the impact of violence on an individual’s well-being, and that helps heal the social and psychological wounds violence leaves in its wake.
HARM REDUCTION
Total adherence or abstinence doesn’t work for all who engage in behaviors harmful to their health, like substance use. Harm reduction leverages the relationship between the care provider and the individual to lower the individual’s health risks. Our providers work with individuals to set goals that both reduce harm and are realistic to achieve.
Our model of care is known in the health care industry as a patient-centered medical home. Because we provide comprehensive care that goes beyond medical care, we call ourselves a health home.
________________________________________
Health Care for the Homeless is Participating in the Maryland Primary Care Program (MDPCP)
Our practice is participating in the MDPCP, a state-wide initiative to improve primary care. To help us provide you with the best care, Medicare will share some of your personal health information with HCH and the State Designated Health Information Exchange (CRISP), to share with other health professionals providing care to you. This will provide us with a more complete picture of your health and allow us to better coordinate your care.
For further information and to opt out of data sharing, read more here.
________________________________________
Health Care for the Homeless is accredited for quality: Health Care for the Homeless is an FTCA-deemed facility and is accredited by the Joint Commission for ambulatory care and behavioral health, and as a patient-centered medical home.
We invite you to apply and join a welcoming team.
Baltimore City – Downtown - 421 Fallsway, Baltimore, MD 21202
Baltimore City – West Baltimore - 2000 W. Baltimore St., Suite 3300 Baltimore, MD 21223
Baltimore County - 9150 Franklin Square Dr., Suite 301 Baltimore, MD 21237
Our Vision
Everyone is healthy and has a safe home in a just and respectful community.
Our Mission
We work to end homelessness through racially equitable health care, housing and advocacy in partnership with those of us who have experienced it.
Our mission: "...to prevent and end homelessness for vulnerable individuals and families by providing quality, integrated health care and promoting access to affordable housing and sustainable incomes through direct service, advocacy and community engagement."
Over 35+ years, we at Health Care for the Homeless have steadily grown and strengthened our approach to care to meet the needs of the vulnerable people we served. We are driven by a single and unwavering goal: to improve access to care for clients, and to provide them with the highest possible quality of care. Continuing in that spirit, we are now implementing a care model that takes quality and access to a new level.
A health home delivers person-centered, whole-person care that is evidence-based, uses data and listens to clients to continuously improve the care we deliver. We have been person-centered and focused on the whole person since the first client walked through our clinic doors in 1985. We’ve also always applied evidenced-based standards to our work and used data to inform our care.
What’s changed is how much we’ve grown over the years: We have more disciplines, staff members and sites. Coordinating all of our activity today requires a more powerful and standardized way of delivering care.
We are a health home.
Five areas of focus
As a health home, we apply five (5) clinical areas of focus to the care we deliver.
ACCESS FOR THOSE WHO NEED US
People should be able to reach us easily when they need help. So we ensure 24/7 access to clinical advice; make our appointment schedules and hours flexible and accommodating; and enable clients to access their health records electronically. We also are increasing our presence throughout the community. We have clinics in dowtown Baltimore, West Baltimore and Baltimore County. And we are continually expanding our street outreach and reaching more people with our mobile clinic.
TEAM-BASED CARE
Whole-person care requires the expertise of many different providers. Done well, it demands collaboration and constant communication among these providers. We are integrating our care providers into multidisciplinary care teams, each with a “panel” of clients, so they can develop care plans that span the range of treatment and services with clients.
CARE MANAGEMENT
Not only are we committed to providing clients with the best possible care; we are committed to positioning them to manage their own care. To that end, we make sure we know which client groups have the highest needs; we share clients' care plans with them and across their care teams; we provide clients with the tools to care for themselves and we make sure they are part of all decisions relating to their care; and we help them manage their medications.
BETTER MANAGE AND COORDINATE CARE
People experiencing homelessness often have complex conditions that require intensive care coordination. Our providers specialize in identifying these particularly vulnerable individuals. They provide them with the multi-disciplinary support that keeps them out of hospital emergency rooms, and they help them develop reasonable, healthy goals for themselves. This coordinated and comprehensive care includes helping individuals put a roof over their heads.
IMPROVE THE HEALTH OF THE LARGER POPULATION
As a population, people without homes have higher rates of chronic disease, such as diabetes, than their housed counterparts. We are using evidence-based guidelines to standardize and expand our assessments for these conditions. And we are continuously seeking ways to help our clients manage and treat their conditions.
________________________________________
Person-centered, whole-person care
We provide person-centered, whole-person care, combining health care services and supportive services with advocacy.
We provide whole-person care in a safe, respectful environment with acute sensitivity to clients’ life experiences. All have endured trauma; many engage in behaviors that pose a risk to their health. Through a trauma-informed and harm reduction approach, we meet individuals where they are, engage them in care with dignity and work to engage them fully in their own overall wellness.
TRAUMA-INFORMED CARE
Trauma is central to the homeless experience. People without homes often experience life trauma before they end up on the street, and living on the street is, in itself, traumatic. Trauma affects everything from our ability to trust others and build relationships to our brain development. For these reasons, we at Health Care for the Homeless are committed to providing trauma-informed care, a best practice that recognizes the impact of violence on an individual’s well-being, and that helps heal the social and psychological wounds violence leaves in its wake.
HARM REDUCTION
Total adherence or abstinence doesn’t work for all who engage in behaviors harmful to their health, like substance use. Harm reduction leverages the relationship between the care provider and the individual to lower the individual’s health risks. Our providers work with individuals to set goals that both reduce harm and are realistic to achieve.
Our model of care is known in the health care industry as a patient-centered medical home. Because we provide comprehensive care that goes beyond medical care, we call ourselves a health home.
________________________________________
Health Care for the Homeless is Participating in the Maryland Primary Care Program (MDPCP)
Our practice is participating in the MDPCP, a state-wide initiative to improve primary care. To help us provide you with the best care, Medicare will share some of your personal health information with HCH and the State Designated Health Information Exchange (CRISP), to share with other health professionals providing care to you. This will provide us with a more complete picture of your health and allow us to better coordinate your care.
For further information and to opt out of data sharing, read more here.
________________________________________
Health Care for the Homeless is accredited for quality: Health Care for the Homeless is an FTCA-deemed facility and is accredited by the Joint Commission for ambulatory care and behavioral health, and as a patient-centered medical home.
We invite you to apply and join a welcoming team.