Hybrid RN Coordinator, Home Visiting & Care Coordination

Greater Lawrence Family Health Center, Inc.; Lawrence (MA); Hybrid; USD 85,000 - 105,000; Full time

Benefits offered by this job

Tuition reimbursement

Comprehensive benefits

Growth opportunities

Great working environment

Job summary

Greater Lawrence Family Health Center, Inc. is seeking an RN Coordinator for our Home Visiting Program in a hybrid role.

You will provide comprehensive care management for medically complex, homebound, and high-risk patients, coordinating across providers, VNA, DME vendors, and CHWs to promote continuity of care and reduce hospitalizations. The ideal candidate holds an active RN license, is bilingual in Spanish, and has experience with telehealth platforms, EHRs, and care coordination workflows.

Qualifications

• Active RN license in good standing
• Bilingual Spanish required
• Experience managing medically complex or high-risk patients
• Strong clinical triage skills and remote management comfort
• Familiarity with DME, VNA, and care coordination workflows
• Ability to collaborate in a team-based care model

Responsibilities

• Provide longitudinal care management for medically complex patients.
• Conduct telephonic or virtual assessments and triage patient concerns.
• Support chronic disease management and monitor changes in clinical status.
• Reinforce care plans, medication adherence, and patient education.
• Perform post-discharge outreach after hospital stays.
• Reconcile medications and review discharge instructions.
• Coordinate follow-up appointments with care team and providers.
• Escalate clinical concerns identified during transitions of care.
• Coordinate across specialists, VNA services, DME vendors, and community orgs.
• Facilitate referrals and ensure completion of specialty care and diagnostics.
• Participate in interdisciplinary team meetings and case conferences.
• Perform planned, non-urgent home visits for vaccines or clinical needs.
• Assess home environment for safety and barriers to care.
• Maintain accurate documentation in the EHR and support quality initiatives.
• Utilize registries and reporting tools for panel management.
• Educate patients and caregivers respecting literacy and cultural context.

Skills

RN license

Bilingual Spanish

Care coordination

Telehealth

Clinical triage

EHR proficiency

Tools

EHR systems

Telehealth platforms

Job description

Greater Lawrence Family Health Center, Inc. is seeking an RN Coordinator for our Home Visiting Program in a hybrid role.

You will provide comprehensive care management for medically complex, homebound, and high-risk patients, coordinating across providers, VNA, DME vendors, and CHWs to promote continuity of care and reduce hospitalizations. The ideal candidate holds an active RN license, is bilingual in Spanish, and has experience with telehealth platforms, EHRs, and care coordination workflows.