HEART Registered Nurse Clinical Coordinator

JOB TITLE: HEART Registered Nurse Clinical Coordinator DEPARTMENT: Medical

Position summary

The RN Clinical Coordinator provides professional nursing assessment, clinical coordination, and care-planning support for the H. E. A. R. T. Homes program. The position promotes safe aging in place by supporting residents, caregivers, and the interdisciplinary care team through health assessment, care coordination, clinical consultation, caregiver education, monitoring of changes in health status, individualized care planning, risk identification, and transition planning. The RN Clinical Coordinator serves as a clinical resource to H. E. A. R. T. Homes staff and caregivers and helps ensure that resident health and safety needs are identified, communicated, and addressed in a timely manner.

The position works collaboratively with residents, families, caregivers, healthcare providers, community partners, and other professionals involved in the resident’s care. The RN Clinical Coordinator does not replace or assume the responsibilities of a resident’s primary care provider, home health agency, skilled nursing service, hospice provider, or other treating healthcare professional. The position provides clinical coordination, consultation, assessment, and oversight only within the RN’s professional scope of practice, applicable Washington State requirements, and the defined scope and policies of the H. E. A. R. T. Homes program.

The RN Clinical Coordinator is administratively supervised by the H. E. A. R. T. Homes Program Manager and maintains professional nursing accountability within the RN’s scope of practice and applicable laws, regulations, and professional standards. The RN Clinical Coordinator has direct access to the Health Services Director or designated clinical authority for clinical concerns, resident safety concerns, professional practice matters, complex clinical situations, or circumstances in which clinical judgment requires escalation beyond the Program Manager’s authority.

JOB

Duties

Clinical assessment and responsibilities

• Participate in initial resident assessments and enrollment-related clinical reviews.
• Conduct nursing assessments within the RN’s scope of practice and program responsibilities.
• Review available medical, nursing, medication, functional, and health histories.
• Assess functional abilities and activities of daily living (ADLs) and instrumental activities of daily living (IADLs), as applicable.
• Evaluate fall, injury, environmental, and other health and safety risks.
• Identify changes in physical, cognitive, behavioral, emotional, or functional status.
• Identify health conditions or changes that may affect a resident’s ability to safely participate in H. E. A. R. T. Homes services.
• Recognize signs and symptoms that may warrant additional medical evaluation or intervention.
• Recommend or coordinate appropriate follow-up with healthcare providers when indicated.
• Document assessments, findings, recommendations, and follow-up activities accurately and timely.
• Maintain appropriate boundaries regarding nursing assessment, clinical consultation, and medical diagnosis or treatment.

Individualized care planning

• Provide nursing input into individualized service and care plans.
• Identify health-related needs, goals, risks, strengths, and potential barriers to safe aging in place.
• Recommend appropriate nursing and caregiver supports within the program’s scope.
• Review care plans following significant changes in health, function, cognition, living circumstances, or caregiver capacity.
• Participate in quarterly, annual, and other required reassessments.
• Recommend modifications to caregiver supports, services, monitoring, or safety interventions when clinically appropriate.
• Ensure health-related recommendations are communicated to appropriate members of the care team.

Health status monitoring

• Review caregiver and staff reports regarding changes in a resident’s health or functional status.
• Monitor trends in falls, injuries, emergency department visits, hospitalizations, changes in function, and other significant health events.
• Identify potential deterioration or emerging health and safety concerns.
• Determine when changes require additional assessment, provider notification, increased monitoring, or escalation.
• Coordinate appropriate follow-up and communicate relevant information to authorized healthcare providers.
• Maintain appropriate documentation of changes in condition and actions taken.

Caregiver education and support

• Provide health-related education and consultation to caregivers within the RN’s scope of practice.
• Educate caregivers regarding resident-specific health conditions, care needs, safety considerations, and individualized care plans.
• Teach caregivers to recognize and appropriately report changes in a resident’s condition.
• Provide education related to fall prevention, infection prevention, emergency response, health and safety practices, and other applicable topics.
• Reinforce appropriate implementation of individualized care plans.
• Participate in caregiver competency assessment or evaluation when appropriate and within program requirements.
• Promote respectful, person-centered approaches to resident care and communication.
• Identify caregiver concerns, limitations, or training needs that may affect resident safety and communicate them to appropriate program leadership.

Healthcare and community care coordinator

• Coordinate communication with primary care providers, specialists, home health agencies, hospice providers, therapists, pharmacies, hospitals, and other healthcare professionals, as authorized.
• Support coordination of hospital and healthcare facility discharge planning.
• Assist with follow-up appointments, referrals, and recommended services.
• Facilitate communication following significant health events, changes in condition, emergency department visits, or hospitalizations.
• Participate in interdisciplinary case conferences and care coordination meetings.
• Promote continuity of information across care settings while maintaining confidentiality and appropriate authorization.
• Assist residents and caregivers in understanding healthcare recommendations and identifying appropriate follow-up resources.

Risk management and quality improvement

• Participate in the review and follow-up of falls, injuries, medication-related concerns, and other health or safety incidents.
• Identify opportunities to reduce preventable health and safety risks.
• Recommend appropriate safety interventions within the program’s scope.
• Participate in emergency preparedness and response planning as assigned.
• Support identification and reporting of suspected abuse, neglect, exploitation, or other reportable concerns in accordance with applicable law and organizational policy.
• Participate in quality assurance and performance improvement activities.
• Identify trends or recurring concerns that may require program-level intervention.
• Maintain compliance with applicable organizational policies, professional standards, and regulatory requirements.

Transition and higher-level care planning

• Identify circumstances in which a resident’s needs may exceed the scope or resources of
• H. E. A. R. T. Homes.
• Conduct or coordinate clinical reassessment when significant changes in condition or function occur.
• Recommend additional healthcare, supportive services, or medical evaluation when appropriate.
• Participate in planning for transitions to higher levels of care or alternative living arrangements.
• Assist with continuity of care during transitions between home, hospital, rehabilitation, skilled nursing, assisted living, and other care settings.
• Support communication with healthcare providers, caregivers, family members, and receiving facilities as authorized.
• Document transition-related recommendations, communications, and follow-up.

Documentation, compliance, and professional practice

• Maintain complete, accurate, timely, and confidential clinical documentation.
• Maintain appropriate records of assessments, care coordination, communications, recommendations, incidents, and follow-up.
• Protect resident privacy and confidential health information in accordance with applicable requirements and organizational policies.
• Practice within the RN’s professional scope, competence, and authority.
• Seek consultation and escalate clinical concerns appropriately.
• Maintain professional boundaries and demonstrate sound clinical judgment.
• Participate in required meetings, training, continuing education, and competency activities.
• Perform other related duties as assigned within the scope of the position and professional licensure.

Minimum qualifications

• Current, active, and unrestricted Registered Nurse (RN) license in the State of Washington.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited nursing program. BSN preferred.
• Experience in geriatric nursing, community health, home health, public health, case management, care coordination, or a related area preferred.
• Demonstrated knowledge of chronic disease management, fall prevention, medication safety, aging-related health concerns, and health risk identification.
• Demonstrated clinical assessment and care coordination skills.
• Strong communication, documentation, organization, and interpersonal skills.
• Experience working within an interdisciplinary care team preferred.
• Experience working with Tribal Health programs, Native American communities, or culturally specific healthcare programs preferred.
• Commitment to respectful, person-centered care and support for Elders and their families.
• Commitment to Swinomish cultural values and respectful engagement with the Swinomish community.

Required knowledge, skills, and abilities

Knowledge

• Knowledge of professional nursing principles, practices, standards, and ethics.
• Knowledge of nursing assessment, care planning, care coordination, and monitoring of changes in health status.
• Knowledge of aging-related health concerns and common chronic conditions affecting older adults.
• Knowledge of geriatric health, functional decline, cognitive changes, fall prevention, and injury prevention.
• Knowledge of medication safety principles, including recognition of potential medication-related concerns and the importance of medication reconciliation and provider follow-up.
• Knowledge of infection prevention and control principles.
• Knowledge of emergency response, health and safety practices, and risk identification.
• Knowledge of community-based healthcare and supportive services.
• Knowledge of interdisciplinary care coordination and transitions of care.
• Knowledge of person-centered care principles and approaches to supporting independence and quality of life.
• Knowledge of applicable nursing laws, regulations, professional standards, confidentiality requirements, and mandatory reporting obligations.
• Understanding of the healthcare needs, preferences, and considerations of older adults and their caregivers.
• Understanding of the role and limitations of community-based programs in relation to primary care, home health, skilled nursing, hospice, and other healthcare services.
• Knowledge of culturally responsive and respectful approaches to working with Native American/Tribal communities and Elders preferred.

Skills

• Strong clinical assessment and observation skills.
• Strong care coordination and case management skills.
• Effective clinical judgment and problem-solving skills.
• Strong written and verbal communication skills.
• Ability to communicate complex health information clearly and appropriately to residents, families, caregivers, and healthcare professionals.
• Strong documentation and recordkeeping skills.
• Ability to recognize changes in condition and appropriately determine when escalation or additional evaluation is warranted.
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