Registered Nurse

Purpose

The Registered Nurse (RN) delivers person-centered, team-based care across psychiatric, medical, and social domains. The RN conducts comprehensive assessments, develops and executes shared care plans with the multidisciplinary team, leads complex case management for individuals with multifaceted needs, provides wound care, coordinates hospital follow‑ups and transitions of care, oversees medication processes, and advances health education and community integration. The RN also identifies operational gaps in workflows, documentation, medication systems, and care coordination—and partners with leadership and the care team to implement improvements that enhance safety, quality and efficiency of services provided.

• Team‑Based Clinical Assessment & Nursing Care

  Perform holistic nursing assessments, document findings, and contribute to shared team‑authored care plans with clear roles, goals, and timelines.

  Provide direct nursing care including vitals, triage, injections, and blood draws; coordinate timely lab follow‑up and closed‑loop communication of results.

  Provide wound care under provider orders, including assessment, cleaning, dressing changes, monitoring signs of infection, and communicating wound progress with care team, escalating concerns, and collaborating with providers/WOCN as needed.

  Monitor chronic and emerging health conditions, surface risks in daily team huddles, and adjust care plans accordingly.

  Review medication orders, oversee administration and timely scheduling to ensure continuity of care for participants.

  Administers injections per licensed prescriber orders.

  Performs blood draws as required per licensed medical providers and coordinates with MA and third‑party lab to get results in a timely manner.

  Monitor and follow up on identified health concerns such as chronic health conditions.

• Complex Medical Case Management & Hospital Follow‑Ups

  Leads the development and coordination of individualized treatment and medical care case management plans addressing medical needs.

  Participates in appropriate case management regarding psychiatric, behavioral, and social needs.

  Considers the importance of social determinants of health when developing treatment plans.

  Provide advocacy and navigation support through healthcare systems, insurance, specialty care referrals, and community‑based resources.

  Ensure continuity of care through coordinated planning, communication, and documentation across multiple services and provider teams.

  Coordinates and completes hospital follow‑ups, including reviewing discharge instructions, reconciling medications, updating treatment plans, facilitating follow‑up appointments and ensuring continuity of care.

  Communicate post‑hospitalization updates to multidisciplinary team and supports participants in connecting to community‑based follow‑up services.

  Assess system or process gaps impacting client outcomes such as delays in service access, care transitions, or hospital discharge coordination and proactively address or elevate them to leadership to ensure continuity and quality of care.

  Proactively advocate for transitions of care (pre‑admission planning, discharge coordination, warm handoffs) ensuring continuity and adherence.

• Collaboration with Multidisciplinary Teams

  Serve as a core member of an interprofessional team (medical, behavioral health, pharmacy, residential, peer support, skills training and intensive case management).

  Actively engage with a multidisciplinary team to plan, coordinate, and evaluate care for participants with complex needs, contributing to clinical judgments and assessments during team collaboration.

  Communicate collaboratively and regularly with treatment team members regarding participants’ medical and health status as appropriate for care planning.

  Educate and train staff on disease processes, wound care basics, medical equipment and evidence‑based practices.

  Collaborate with team members to recognize system‑level barriers or workflow challenges and participate in developing solutions that strengthen care coordination and service delivery.

• Community Support & Participant Engagement

  Coordinate and support client access…