Nurse Case Manager, Outreach

Boston Health Care for the Homeless Program

$83K — $120K *
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Registered Nurse license in Massachusetts required.
  • Bachelor's degree in nursing preferred; minimum 2 years in outpatient care essential.
  • HIV primary care experience highly valued.
  • ACRN certification preferred, with funding available for post-hire training.
  • Strong knowledge of substance use disorder and risk reduction principles favored.
  • Experience working with homeless populations is strongly preferred.
  • Mental health experience and familiarity with trauma-informed care are advantageous.

Responsibilities

  • Conducts nursing assessments and triage for incoming HIV patients, utilizing approved protocols and EHR documentation.
  • Implements and communicates the patient-centered care plan and monitors patient progress.
  • Administers vaccines and injectable medications, provides adherence counseling and directly observed therapy as necessary.
  • Coordinates care with behavioral health staff and conducts outreach to provide care in community settings.
  • Supports chronic disease management for HIV and related co-morbidities by addressing barriers to care.
  • Assists with medication coordination for substance use disorder treatments and coordinates preventative services for patients.
  • Fosters a supportive environment for patients and team, engages in continuous improvement and orientation of new staff.

Benefits

  • $4,000 sign-on bonus available.
  • Competitive paid time off program offered for full-time employees.
  • Health, dental, and vision insurance provided.
  • 403B retirement savings plan accessible to employees.
  • Pre-tax MBTA pass program with a 40% discount available.
  • Additional pay considerations for bilingual proficiency.
Full Job Description
Job Summary:
***NOW OFFERING A $4,000 SIGN ON BONUS***

Hours: Monday - Friday, 8:00 am-5:30 pm - full-time or part-time schedule possible
Union: No
Union Name: n/a
Patient Facing: Yes

Are you an RN looking for an opportunity to combine clinical nursing with meaningful community outreach?

We are seeking an HIV Nurse Case Manager to join a dynamic, multidisciplinary HIV primary care team nationally recognized as a model of excellence.

In this role, you will build trusting relationships with patients and provide compassionate, non-judgmental nursing care across a variety of settings-including outpatient clinics, shelters, drop-in centers, street outreach locations, and patients' homes. Working alongside medical providers, case managers, social workers, behavioral health professionals, and other nurses, you will help ensure that patients receive coordinated, comprehensive care wherever they are.

Your clinical responsibilities will include HIV and chronic disease management, nursing assessment, triage, care coordination, medication adherence support, health education, and behavioral risk-reduction counseling. You will respond to both routine and urgent patient needs and help ensure clear communication and continuity of care across the multidisciplinary team.

This is an opportunity to take nursing beyond the traditional clinic setting and make a lasting impact by connecting people experiencing homelessness and living with HIV to care, supporting ongoing engagement and retention in treatment, and helping patients achieve and sustain their health and wellness goals.

This position is funded until the end of March 2028 with the possibility for renewal. If this funding is not renewed, this position will end March 31, 2028.

Responsibilities:
  • Provides outpatient primary care nursing including medical assessments and triage services for HIV team patients coming in for same-day or scheduled visits; conducts virtual, telephonic, or in-person nurse assessment and triage to assess the severity of the patient's health concerns using approved protocols and resources to advise appropriately. Documents patient information accurately and in a timely manner in the EHR.
  • Implements the patient-centered plan of care, evaluates outcomes, and regularly communicates the plan of care, patient status, and progress toward goals with the patient and care team members; conducts comprehensive intake assessments for new HIV team patients.
  • Administers vaccines, injectable medications, and provides wound assessment and wound care as indicated; provides medication adherence assessments and counseling. Provides directly observed therapy when indicated with support of outreach team members.
  • Coordinates care with integrated HIV team behavioral health staff. Along with other team members, visits patients at shelters and other outreach sites to provide nursing care and care coordination services and identify barriers to medication adherence and engagement in care.
  • Provides chronic disease management support for HIV as well as other common co-morbid medical conditions such as diabetes and hypertension. Identifies any structural barriers patients face in accessing medical care and adhering to HIV medications, and works with the interdisciplinary team to address those barriers (e.g., housing, transportation, drug treatment, food, clothing, benefits, etc.)
  • Assists medical providers in coordinating follow up related to the provision of medication (such as buprenorphine and naltrexone) for opioid use disorder and other substance use disorders. Coordinates preventative services for HIV team patients including, but not limited to, education, preventative medications, vaccinations, testing, and referrals.
  • Promotes a compassionate and therapeutic environment that is responsive to the unique patient population and extends to members of the care team; demonstrates initiative and commitment to continuously improve services and processes that positively impact patient care and organizational goals. Participates in training and orientation of new nursing staff as directed by Supervisors.
  • Exhibits a positive attitude with patients and establishes professional and respectful relationships with the internal and external healthcare team members, agencies, and healthcare facilities.
Qualifications:
  • Licensed as a Registered Nurse in the Commonwealth of Massachusetts.
  • Bachelor's degree in nursing preferred; 2 years of experience working in an ambulatory/outpatient care environment required. HIV primary care experience strongly preferred.
  • Certification as AIDS Certified Registered Nurse (ACRN) preferred; however, this can be obtained after being hired, and program funding available to support this training.
  • Expertise in substance use disorder and risk reduction principles, strongly preferred.
  • Experience working with people experiencing homelessness strongly preferred.
  • Mental Health experience, including knowledge of trauma informed care, a plus.
  • Experience working in a community health center setting, a plus.
  • Phlebotomy experience preferred or training upon hire
Compensation and Benefits:
***NOW OFFERING A $4,000 SIGN ON BONUS***
  • The compensation increases based on years of experience and ranges from $40.00 - $58.00 hourly.
  • BHCHP full time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan, pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more. Benefits are prorated for part-time employees.

Does this amazing opportunity interest you? Then we'd love to hear from you.

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