Registered Nurse - Transitional Care

Colorado Coalition for the Homeless; Denver (CO); Hybrid; USD 85,000 - 100,000; Full time

Benefits offered by this job

Health Insurance - HMO or PPO

Dental plans

Vision insurance

Flexible spending accounts

403(b) retirement savings matching

Extensive paid time-off

Job summary

The Colorado Coalition for the Homeless is seeking a Transitional Care Management Registered Nurse to deliver high-quality nursing care to people experiencing homelessness and housing instability. You will coordinate transitions between hospitals, clinics, and community settings, assess needs, connect patients to resources, and document care in the EHR.

The hybrid role at Stout Street Health Center supports remote outreach, care coordination, and team collaboration while ensuring direct patient

Qualifications

• Associate’s, Bachelor’s or Master’s degree in Nursing from an accredited school.
• Current Registered Nurse licensure in the State of Colorado.
• Basic Life Support certification is required.

Responsibilities

• Provide skilled nursing care according to standards and CCH protocols.
• Deliver patient-centered care addressing physical, emotional, and social needs.
• Conduct triage assessments and provide care recommendations.
• Educate patients on managing chronic and acute health conditions.
• Administer medications safely per protocols.
• Collaborate with a multidisciplinary team to ensure comprehensive care.
• Document all patient interactions in the EHR.
• Mentor new nurses and nursing students; participate in quality improvement.

Skills

Nursing care

Patient education

Care coordination

EHR documentation

Triage

Education

Associate’s, Bachelor’s or Master’s degree in Nursing

Colorado RN licensure

Basic Life Support (BLS)

Job description

This position will be posted for a minimum of 5 days.

Coalition Mission

The mission of the Colorado Coalition for the Homeless is to work collaboratively toward the prevention of homelessness and the creation of lasting solutions for families, children, and individuals who are experiencing or at-risk of homelessness throughout Colorado.

The Coalition advocates for and provides a continuum of housing and a variety of services to improve the health, well-being, and stability of those it serves.

Our Philosophy of Service

We believe all people have the right to adequate housing and health care. We work to remove the barriers that restrict access to these rights. Society benefits when adequate housing and healthcare are available to everyone.

We Create Lasting Solutions To Homelessness By

• Honoring the inherent dignity of those we serve, affirming their capabilities, and fostering their hope that a better life is possible;
• Building strong, caring, and trauma-informed communities through the integration of housing, health care, and supportive services;
• Advocating for social and racial equity, inclusion, and diversity and challenging the status quo in partnership with our workforce members and those we serve;
• Achieving excellence through continuous quality assurance, innovation, and professional development;
• Using resources judiciously and effectively.

The Transitional Care Management (TCM) Registered Nurse delivers high-quality, compassionate nursing care to people experiencing homelessness or housing instability. The TCM RN supports patients as they transition between hospitals, emergency departments, skilled nursing facilities, outpatient providers, and community settings, working collaboratively within the Integrated Health Services (IHS) team and with partner hospitals to improve discharge outcomes, expand access to hospital follow-up visits at CCH, reduce avoidable readmissions, and improve continuity of care. The TCM RN coordinates health care transitions for CCH patients; assesses patient needs and goals, connects patients to appropriate resources; and performs both independent and delegated nursing duties. The TCM RN also provides nursing and triage support to the CCH Respite team and on-site nursing support at Stout Street Health Center (SSHC) and affiliated satellite clinics as needed.

Duties/Responsibilities

• Provide skilled nursing care according to community standards and CCH protocols.
• Deliver comprehensive patient-centered care, addressing physical, emotional, and social needs.
• Conduct rapid and accurate triage assessments, providing appropriate care recommendations.
• Educate patients on managing chronic and acute health conditions.
• Administer medications safely and effectively as per protocols.
• Collaborate closely with a multidisciplinary healthcare team to ensure holistic patient care.
• Facilitate access to internal programs such as health outreach and housing support services.
• Oversee care for patients with transitional, chronic, and complex health conditions.
• Mentor new nurses and nursing students, enhancing their clinical skills and confidence.
• Document all patient interactions and care activities in the electronic health record (EHR).
• Engage in continuous professional development and participate in quality improvement initiatives.
• Provides patient-centered care within an integrated, trauma-informed, culturally-aware, harm-reduction model
• Ability to perform quick and accurate triage assessments with appropriate recommendations of care as outlined in SSHC nursing protocols via telephone or in-person
• Empowers patients by providing appropriate health education and information, including but not limited to addressing common chronic and acute health conditions in this population, such as diabetes management, hypertension management, nutrition, wound care, infectious disease, gender affirming care, family planning including parenting, adoption and abortion, and disease prevention.
• Collaborates with other members of the multi-disciplinary health care team and coordinates care with internal programs.
• As a member of an OBH licensed Substance Use Disorder (SUD) treatment team, provides treatment services such as case management, crisis services, initial intake program screenings, individual medication assisted treatment (MAT) counseling, and administering scales to assess withdrawal.
• Provide nursing services as needed to all CCH programs and facilities.
• Preceptor to new nurses and nursing students
• Participates in team-based or interdisciplinary quality improvement initiatives
• Attends required disciplinary, inter-disciplinary, suite, quality improvement, and all-staff meetings
• Ability to work day, evening or weekend clinic as scheduled or appropriate.
• Ensure timely, accurate documentation of all clinical services, communications, and patient records in the EHR.
• Monitor EHR inboxes for CCH patients who have experienced and Emergency Room or hospital admission and assist them with PCP follow up planning.
• Assist with medical case management of patients with high ED utilization, with the goal of reducing hospital admissions through robust primary care.
• Performs other duties as assigned.

Job Qualifications And Competencies

• Education
  • Associate’s, Bachelor’s or Master’s degree in Nursing from an accredited college or university.
  • Current Registered Nurse licensure in the State of Colorado.
  • Basic Life Support certification.
• Experience
  • Preferred experience in ambulatory, public, community, mental health, or emergency nursing.
  • Familiarity with diverse or marginalized communities is highly desirable.
• Preferred Qualification
  • Bilingual preferred

Work Location and Schedule

This position is based at Stout Street Health Center. The role is eligible for a hybrid work arrangement, which may include a combination of remote, onsite, and community-based work. Duties that can be performed effectively offsite, including telephone or virtual patient outreach, care coordination, documentation, and team collaboration, may be performed remotely with supervisor approval.

Regular onsite and community-based work is required for direct patient care, in-person meetings, training, coverage, and other operational needs. The specific hybrid schedule will be established with the supervisor and subject to change based on patient, program, team, and operational needs, up to and including a return to fully onsite work.

Hybrid work at CCH is a flexible arrangement, not a guarantee. To support safe and effective remote work, this role requires reliable internet access, a private and confidential workspace suitable for handling protected health information (PHI), and compliance with CCH privacy, security, remote-work, and HIPAA policies. CCH may adjust hybrid arrangements based on operational needs, patient care requirements, or program changes.

• Work is performed at CCH clinical settings, in the field (including hospitals, shelters, and environments not meant for human habitation), and, when authorized, remotely from an approved workspace. The allocation of onsite, remote, and field-based work may vary at CCH’s discretion based on patient, team, and operational needs.
• Schedule options may include five 8-hour shifts or four 10-hour shifts, based on supervisor approval and program needs.
• All hours worked, whether remote or onsite, must be recorded accurately in the CCH timekeeping system in accordance with CCH policy and applicable wage-and-hour law.

Coalition Benefits

We offer a full suite of benefits for our eligible employees and their dependents. We’re proud to offer same-and opposite-sex domestic partner coverage.

• Health Insurance - HMO or PPO
• Dental plans, vision insurance, flexible spending accounts, supplemental life insurance
• Company paid basic life and AD&D insurance coverage, Employee Assistance Program, 403(b) retirement savings matching,
• Extensive paid time-off, including holidays, sick leave, and vacation

The effective date for your benefits will be the first of the month following your date of hire.

Employees must be able to perform the essential functions of this position with or without reasonable accommodation and without posing a direct threat to the health or safety of themselves or others. CCH is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any characteristic protected by law.