Care Coordinator-RN

Job Description

ACTS is committed to the  safety of our workforce and persons served. At this time, ACTS is requiring all potential employees to be fully vaccinated before their first day of employment.

The Care Coordinator is a Registered Nurse who provides community-based care coordination, medical and disease education, and outreach services to assist patients in navigating health care transitions, and support patient empowerment through health education and coaching. Services will be provided at scattered, community-based housing units.

Core Responsibilities/Essential Functions:

Conducts medical assessments for development and maintenance of care plans and promoting health programs and services

Provides patient healthcare  Care planning based upon the nursing process to include:  assessment, plan, implementation/intervention and evaluation, as well as a method for monitoring and intervening. 

Makes appropriate referrals and provide resources to support patient/families in self-management to meet health care treatment goals, assess readiness to learn and validate learning outcomes.

Work collaboratively with interdisciplinary teams and health care team members both internal and external to the organization to improve patient care through effective utilization and monitoring of health care resources

Facilitate pre-planning, patient education and empowerment, and assessment of patient barriers to support the most effective and efficient interactions between patients and providers.

Assist patient and providers from across the care continuum to ensure post-emergency department, hospitalization, and/or specialist follow up. 

Utilize electronic health record to appropriately document interactions, findings, and continuum of care-related activities.  

Participate in evaluating outcomes at the individual level with each patient/client and at the same time participate in agency-wide evaluative efforts to ensure and improve the oeverall quality of service being delivered.

Completes pre-admission medical screening of clients to determine admission eligibility; apply nursing principles and practices in the care and treatment of clients, administer and read PPDs, and makes assessment of clients' conditions and documents per services provided, completes and records vital signs,  observes and assesses clients for deviations from normal conditions/behaviors

Within limits of licensure, administers and/or assists with medication/narcotics/treatments as prescribed by protocol or physician's order .

Adheres to regulatory bodies and licensing rules, guidelines and all established protocol to carry out all duties required by contract, licensure, accreditation, and certification relative to program or service assignment.

Participates in "on-call" rotation for afterhours  responsibilities 

Performs other duties as assigned.

Pre-requisite Requirements:

  • Active licensure as a registered professional nurse in accordance with Florida Law.

  Two(2) years of general nursing experience in a clinical setting

  Case Coordination with chronically homeless population preferred.

  Must possess valid Florida Drivers' License, industry accepted driving history and maintain vehicle insurance required by State of Florida.

Supervision:  This position provides supervision to LPNs and Nursing Assistants (where applicable), and reports to the Team Leader.

The omission of specific statements does not preclude management from assigning specific duties not listed herein if such duties are a logical assignment to position.