Integrated Care Coordinator Nurse

Provides first point of clinic contact for all new clients. Explain services available and focus on engagement of client to access services.

• Completes health screenings, nursing assessments and triage healthcare needs for new and ongoing clients.
• Participates in team meeting to develop a plan of care to address client needs.
• Assists clients in navigating the healthcare environment to ensure access to appropriate care.
• Advocates on client’s behalf with healthcare providers and managed care organizations to ensure timely care.
• Assists with coordination/access to services that address social determinants of healthcare outcomes:
  • Provides transportation to healthcare appointments, when needed
  • Identifies other needs, when necessary, that ensure access to healthcare
  • Assists in obtaining access to housing (search for housing, applications, financial assistance, communication with landlord), as necessary, when housing status destabilizes health status and presents a barrier to receiving appropriate healthcare.
  • Assists with access to other community resources e.g., public assistance and financial benefits.
• Develops knowledge base of other healthcare providers in the service area and collaborate, as needed
• Documents tracking for appointments, medication, and other healthcare needs for assigned clients, as needed
• Provides education and support wellness activities such as such as healthy eating, physical activity, and healthy behaviors
• Assists clients who have recently discharged from inpatient treatment, incarceration, residential care, and/or Emergency Department visits to ensure a transition to outpatient care using evidence-based transitional/navigation services to prevent readmissions.
• Provides caring contacts to clients estimated to be at high risk for suicide to ensure continuity of care.
• Collaborates with client, family/significant others to develop support networks.

• Education:
  • Licensed Practical Nurse preferred with current active license to practice in Kentucky.
  • Medical Assistant may be considered based on academic preparation and relevant experience

• Experience:
  • Three years of nursing experience in a hospital, physician office, or behavioral care clinic.
  • Experience in community setting or integrated care environment

• Position may require lifting of 20 pounds maximum, with frequent lifting or carrying of items weighing up to 10 pounds, or requires significant periods of walking or standing
• Possible exposure to the threat of bodily harm from clients or families.
• Normal tasks may involve exposure to blood, bodily fluids, or tissue.
• Reliable transportation for frequent travel.

Within the bounds of their respective job descriptions, all staff are expected to exercise principle-centered leadership, focused on customer service responsiveness, with a continuous quality improvement orientation. Additionally, all staff are expected to develop a working knowledge of and follow all policies and procedures related to safety management and other Joint Commission standards.

Time Type:
Full time