RN Care Navigator — Home Visiting & Transitions

Lawrence Partnership; Lawrence (MA); Hybrid; USD 78,000 - 91,000; Full time

Benefits offered by this job

Tuition reimbursement

Job summary

Greater Lawrence Family Health Center (GLFHC) seeks an RN Coordinator for the Home Visiting Program. The role provides comprehensive care management for medically complex, homebound, and high-risk patients in a hybrid setting, coordinating across providers, VNA, and DME vendors to promote continuity of care and reduce hospitalizations.

The RN will perform telehealth assessments, manage chronic conditions, educate patients and caregivers, and ensure timely transitions of care with strong

Qualifications

• Active RN license in good standing required.
• Experience managing medically complex or high-risk patients.
• Strong clinical triage and remote patient management skills.
• Familiarity with DME, VNA, and care coordination workflows.
• Excellent communication, organization, and teamwork ability.
• Comfort with telehealth platforms and electronic health records.

Responsibilities

• Provide longitudinal care management for medically complex patients.
• Conduct telephonic/virtual assessments and triage concerns.
• Support chronic disease management and monitor clinical status.
• Reinforce care plans, med adherence, and education.
• Coordinate follow-up appointments with providers and navigators.
• Escalate clinical concerns during transitions of care.
• Collaborate with VNA, DME vendors, and community organizations.
• Participate in interdisciplinary team meetings and case conferences.
• Occasionally perform planned home visits for vaccinations or needs.
• Document in the EHR and support quality initiatives.

Skills

RN license

Care coordination

Telehealth

Clinical triage

Remote patient management

EHR systems

Job description

Greater Lawrence Family Health Center (GLFHC) seeks an RN Coordinator for the Home Visiting Program. The role provides comprehensive care management for medically complex, homebound, and high-risk patients in a hybrid setting, coordinating across providers, VNA, and DME vendors to promote continuity of care and reduce hospitalizations.

The RN will perform telehealth assessments, manage chronic conditions, educate patients and caregivers, and ensure timely transitions of care with strong