RN Care Coordinator - Home Visiting & Telehealth

Greater Lawrence Family Health Center; Lawrence (MA); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Benefits package

Tuition reimbursement

Growth opportunities

Tuition assistance

Job summary

Greater Lawrence Family Health Center (GLFHC) is hiring an RN Coordinator for the Home Visiting Program. You will provide comprehensive care management for medically complex, homebound patients, coordinating across providers, VNA services, and community resources.

Telehealth and home visits will be part of your responsibilities. You will work under the Site Nurse Manager in a hybrid model, ensuring safe transitions of care, medication reconciliation, and adherence support, while promoting

Qualifications

• Active RN license required.
• Bilingual Spanish required.
• Experience managing medically complex or high-risk patients.
• Strong clinical triage skills and comfort with remote patient management.
• Familiarity with DME, VNA services, and care coordination workflows.
• Strong clinical judgment, communication, and organizational skills.
• Comfortable utilizing telehealth platforms and electronic health records.
• Ability to manage complex and multifaceted patient needs.
• Strong care coordination skills and ability to collaborate within a team-based model.
• Commitment to patient-centered and equitable care.

Responsibilities

• Provide longitudinal care management for medically complex, homebound patients.
• Conduct telephonic and/or virtual assessments and triage concerns.
• Support chronic disease management and monitor clinical status.
• Reinforce care plans, medication adherence, and caregiver education.
• Perform post-discharge outreach and discharge reconciliation.
• Coordinate follow-up appointments across multiple providers and services.
• Escalate clinical concerns during transitions-of-care outreach.
• Coordinate across VNA, DME vendors, and community organizations.
• Facilitate referrals and ensure completion of specialty care and diagnostics.
• Participate in interdisciplinary team meetings and case conferences.
• Occasionally perform planned home visits for vaccinations or clinical needs.
• Assess home environment for safety and barriers to care.
• Maintain accurate EHR documentation and support quality initiatives.

Skills

Bilingual Spanish

Care coordination

Clinical triage

Team collaboration

Telehealth proficiency

Education

Registered Nurse (RN) License

Tools

EHR systems

Telehealth platforms

Care coordination tools

Job description

Greater Lawrence Family Health Center (GLFHC) is hiring an RN Coordinator for the Home Visiting Program. You will provide comprehensive care management for medically complex, homebound patients, coordinating across providers, VNA services, and community resources.

Telehealth and home visits will be part of your responsibilities. You will work under the Site Nurse Manager in a hybrid model, ensuring safe transitions of care, medication reconciliation, and adherence support, while promoting