Registered Nurse - Care Coordination

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Community Health Connections (CHC) is a multi‑site, non‑profit health care center offering urgent care, primary family medical and pediatric care, preventative and restorative dental care, oral surgery, behavioral health services for children and adults, substance use disorder treatment, and specialty services including optometry eye care, optical shop, acupuncture, nutrition consultations and podiatry. CHC is mission‑driven, providing compassionate, quality health care regardless of income or health insurance status.

CHC has five sites within Fitchburg, Gardner and Leominster with decades of experience as a Federally Qualified Health Center (FQHC), serving 36 communities in North Central Massachusetts.

The Care Coordinator performs an integral role in the team‑based approach to care, developing collaborative relationships with providers, patients and their significant others and other members of the care team. He/she ensures that high‑risk patients receive care that is consistent with national, state and health center standards and policies. The Care Coordinator supports patients and families in self‑management, through evidence‑based approaches as appropriate, engages in health center projects aimed at specific patient population needs, and utilizes effective and appropriate communication strategies for issues such as health literacy and cultural norms when working with patients.

The RN Care Coordinator partners with Care Coordination Specialists and interpreters to ensure that patients are able to access culturally and linguistically appropriate services in a timely and cost‑effective manner. He/she participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.

• Complete an initial assessment actively involving the patient to determine care coordination needs.
• Utilize Motivational Interviewing techniques, create and update care plans addressing identified needs, and emphasize patient‑specific goals and self‑management as they relate to desired medical outcomes. Partner with the patient to encourage active participation in identifying the patient’s own goals.
• Utilize a collaborative approach with the PCP and other team members to create a comprehensive action plan that ensures the patient receives a consistent message from all team members.
• Utilize behavioral strategies to assist patients in adopting healthy behaviors, improving self‑care and managing chronic disease, focusing on educating and optimizing the member’s/family’s level of independence in navigating the health care system at all levels of the continuum.
• Plan, coordinate, monitor, and evaluate progress toward meeting goals in the plan of care.
• Serve as a liaison and patient advocate between providers, the health center, and community resources to facilitate access to services and improve the quality of those services.
• Educate patients on and/or assist with establishing advanced directives.
• Integrate the patient/family members into care coordination and care management planning and communications, ensuring the patient/family are informed and supported in decision‑making.
• Provide ongoing verbal and written communication of the patient’s needs, plan of care, progress, and changes in status with the PCP, team, and the patient/family through comprehensive physical, mental, and psychosocial assessments.
• Execute medical orders for specific drugs, treatments, and other diagnostic or therapeutic procedures.
• Administer and record medication administration consistent with knowledge of pharmacology.
• Follow health center policy regarding medication administration.
• Administer routine vaccines when not administered as part of office visits; remain knowledgeable of current and catch‑up vaccine schedules and comply with vaccine storage guidelines set by the MA DPH.
• Participate in preventive health teaching and education pertaining to procedures being conducted.
• Work with the primary care provider and other team members to plan and coordinate complications related to the transition of care for patients discharged from…