Company Overview
Duffy Health Center, a non-profit organization located in Hyannis, MA, provides compassionate, integrated healthcare for individuals experiencing homelessness, housing instability, and complex medical and behavioral health needs on Cape Cod.
As a Federally Qualified Health Center (FQHC), Duffy Health Center delivers care through interdisciplinary, trauma-informed, and patient-centered models. Our staff are deeply committed to equity, dignity, and innovation in healthcare delivery. Many team members bring lived experience and a strong dedication to serving vulnerable populations.
Position Summary
The Medical Respite and Population Health Program Coordinator is an RN-required role responsible for coordinating and improving Duffy Health Center’s Medical Respite and population health operations, including clinical, care management, compliance, quality, and data functions. Working under the Medical Director’s leadership and in collaboration with the Director of Nursing, this position helps ensure that Medical Respite workflows, patient transitions, interdisciplinary communication, documentation, and reporting are reliable, coordinated, and aligned with patient care goals.
This RN-required community health nursing and program coordination role relies on clinical judgment, care management expertise, nursing assessment review, clinical risk identification, medication and discharge-plan review, patient education coordination, and timely escalation of clinical concerns. The coordinator serves as the central liaison across medical respite, primary care, behavioral health, nursing, care management, hospital discharge planning, home health care, housing, and community-based homeless services.
The role supports safe recovery, continuity of care, regulatory readiness, population health performance, and measurable outcomes for medically vulnerable individuals experiencing homelessness, housing instability, and complex medical, behavioral health, and social needs.
Salary Range $95,000- $105,000
The posted range represents the full earning potential for the role over time, not the typical starting or hiring rate. Starting pay is determined based on factors such as relevant experience, skills, internal equity, and market alignment. The top of the range reflects compensation that employees may reach through demonstrated performance, increased responsibilities, and tenure in the role. This structure allows us to support growth and advancement while maintaining fairness and consistency across the organization.
Key Responsibilities
Program Coordination, Medical Respite Operations & Transitional Care
· Lead daily Medical Respite program coordination, including referral management, eligibility screening support, intake readiness, admission coordination, service tracking, discharge planning, and post-discharge follow-up.
· Serve as the primary coordination contact for hospital discharge planners, respite partners, primary care, behavioral health, nursing, care management, housing, home health, and community-based service providers.
· Apply RN clinical judgment when reviewing referral materials, discharge summaries, medication lists, treatment plans, and follow-up recommendations to identify patient risk, care management needs, documentation gaps, and operational barriers.
· Coordinate individualized care plans that support medical stabilization, medication access, follow-up care, behavioral health needs, substance use treatment connections, housing navigation, benefits, transportation, and other enabling services.
· Monitor patient progress throughout the respite episode and escalate clinical, functional, behavioral health, safety, documentation, or discharge barriers to the appropriate clinical or operational leader.
· Facilitate safe, timely transitions from Medical Respite to primary care, specialty care, behavioral health, housing, shelter, community nursing, recovery supports, and other community-based services.
· Partner with hospitals and community providers to reduce avoidable emergency department use, preventable readmissions, treatment gaps, and unsafe discharge outcomes.
· Maintain program workflows aligned with applicable MassHealth Homeless Medical Respite Services requirements, including administrative, documentation, reporting, billing, quality, and adverse-incident expectations.
RN Care Management, Clinical Risk Review & Integrated Care Coordination
· Use RN clinical judgment to review nursing assessments, discharge instructions, medication lists, chronic disease needs, wound care plans, follow-up requirements, and patient-specific risk factors.
· Identify clinical, behavioral health, substance use, functional, social, and environmental risks that may affect respite eligibility, recovery, care plan completion, or discharge readiness.
· Coordinate care management interventions for high-risk patients, including appointment coordination, medication access, patient education, treatment-plan reinforcement, chronic disease stabilization, and connection to enabling services.
· Provide patient education within RN scope regarding medications, disease management, wound care instructions, self-management strategies, follow-up care, and when to seek urgent or emergent care.
· Coordinate with providers and nursing leadership regarding changes in patient status, unresolved clinical concerns, missed care transitions, medication discrepancies, or safety risks.
· Support integrated care activities with primary care, behavioral health, nursing, substance use treatment, housing, shelter, outreach, and social service partners.
· Document patient-centered care plans, care management activities, clinical risk reviews, coordination efforts, identified barriers, patient education, and escalation actions in accordance with organizational policies and clinical documentation standards.
· Support trauma-informed, low-barrier, culturally responsive service delivery for individuals experiencing homelessness and housing instability.
Interdisciplinary Collaboration
- Collaborate closely with:
- Primary care providers
- Behavioral health clinicians
- Case managers
- Hospital discharge planners
- Community agencies
- Visiting nurse agencies
- Housing and social service organizations
- Participate in interdisciplinary huddles and case reviews
- Facilitate communication between care teams and external partners
Compliance, Regulatory Readiness & Program Standards
· Maintain working knowledge of MassHealth Homeless Medical Respite Services regulations, including provider eligibility, scope of services, staffing, supervision, recordkeeping, written policies, reporting, adverse incident reporting, quality management, member communications, and service limitations.
· Support HRSA Health Center Program compliance expectations, including required services, clinical staffing, credentialing alignment as applicable, quality improvement/assurance, confidentiality, patient safety, patient experience, and documentation standards.
· Assist with internal audits, readiness reviews, corrective action tracking, policy implementation, and evidence collection for regulatory, payer, grant, and accreditation-related requirements.
· Escalate compliance risks, patient safety concerns, operational gaps, or documentation deficiencies to the Medical Director, Director of Nursing, and other appropriate leaders.
Program Management, Workflow Development & Operational Improvement
· Coordinate Medical Respite program operations, workflows, referral pathways, communication structures, care management processes, and interdisciplinary meeting routines.
· Develop, maintain, and improve tools, trackers, templates, checklists, and workflows that support timely referral review, eligibility determination, admission readiness, care plan completion, discharge planning, and follow-up.
· Monitor program capacity, referral volume, admission trends, length of stay, discharge barriers, care coordination gaps, and recurring workflow issues.
· Assist with implementation of policies, procedures, standard work, clinical workflows, and quality improvement activities related to Medical Respite and population health.
· Prepare operational summaries and recommendations for the Medical Director, Director of Nursing, and interdisciplinary leadership to support program planning and decision-making.
· Maintain program workflows that support low-barrier access, equitable service delivery, timely communication, and coordination across Medical Respite and population health teams.
Quality, Data & Reporting
· Collect, validate, monitor, and report program data related to referrals, admissions, eligibility, length of stay, discharge disposition, service utilization, readmissions, emergency department use, care plan completion, follow-up appointments, and other quality indicators.
· Use electronic health record data, registries, dashboards, and payer or grant reports to identify care gaps, high-risk patients, workflow issues, and opportunities for quality improvement.
· Support UDS, HRSA, MassHealth, payer, grant, and internal reporting needs as assigned, ensuring data integrity, timely documentation, and confidentiality of protected health information.
· Prepare summaries, trend analyses, and actionable recommendations for the Medical Director, Director of Nursing, and interdisciplinary leadership to support program improvement and strategic decision-making.
Population Health & Value-Based Care
- Support high-risk patient management initiatives
- Promote preventive care and chronic disease stabilization
- Improve patient engagement in primary care services
- Reduce avoidable emergency department visits and hospital readmissions
- Support value-based care performance metrics and quality outcomes
Population Served
This RN-required program coordinator role supports individuals experiencing homelessness, housing instability, and complex medical, behavioral health, and social needs by coordinating Medical Respite operations, care management workflows, integrated care transitions, compliance infrastructure, quality improvement, and population health data systems.
Qualifications & Skills
Education
- Graduate of an accredited school of nursing required
- Bachelor of Science in Nursing (BSN) preferred
Licensure & Certifications
· Current unrestricted Registered Nurse license in Massachusetts required; RN licensure is an essential qualification for this position.
- BLS certification required
- Care management, ambulatory care, population health, or case management certification preferred
Experience
· Minimum of 3 years of RN experience required, including experience applying clinical judgment in care coordination, care management, transitional care, community health, ambulatory care, or comparable settings.
- Experience in one or more of the following preferred:
- Care management
- Community health
- Ambulatory care
- Transitional care
- Medical respite
- Homeless healthcare
- Behavioral health integration
- Chronic disease management
- Case management
- Population health
o Compliance, quality improvement, health center operations, data reporting, or regulatory readiness
Knowledge, Skills & Abilities
· Strong RN clinical judgment, care management, clinical risk review, and care coordination skills.
- Knowledge of community health and social determinants of health
- Ability to manage complex patient populations
- Excellent communication and interdisciplinary collaboration skills
· Strong program coordination, workflow management, follow-through, and cross-functional communication skills.
- Experience working within electronic health records
- Ability to work independently and prioritize effectively in a fast-paced environment
- Commitment to trauma-informed, patient-centered care
· Ability to interpret regulations, translate requirements into workflows, and monitor documentation and data for accuracy, completeness, and compliance.
· Strong analytic skills, including comfort using reports, dashboards, registries, and electronic health record tools to support population health and quality improvement.
Preferred Competencies
- Knowledge of:
- HRSA Health Center requirements
- PCMH standards
- ACO/value-based care models
- Homeless healthcare systems
- Community resource coordination
o MassHealth Homeless Medical Respite Services regulations and provider reporting expectations
o HRSA Health Center Program compliance, quality improvement/assurance, UDS reporting, and confidentiality requirements
- Experience with quality improvement and workflow optimization
- Familiarity with interdisciplinary team-based care models
Physical & Environmental Requirements
- Ability to travel between program sites and community locations as needed
- Ability to sit, stand, walk, bend, and lift up to 25 pounds occasionally
- Ability to work in community-based and nontraditional healthcare settings
Organizational Impact
This role is critical to advancing Duffy Health Center’s mission by strengthening:
- Community-based care coordination
- Transitional care services
- Medical respite clinical operations
- Chronic disease management
- Patient-centered care delivery
- Health equity initiatives
- Value-based care performance
The Medical Respite and Population Health Program Coordinator is a true program coordination role with RN-required care management responsibilities. The position strengthens coordinated, compliant, data-informed, and patient-centered care across the Medical Respite continuum while using RN clinical judgment to identify risk, support care planning, coordinate transitions, and escalate clinical, compliance, operational, and quality concerns to the Medical Director, Director of Nursing, and interdisciplinary leadership as appropriate.
Pay: $95,000.00 - $105,000.00 per year
Benefits:
- 403(b)
- Dental insurance
- Flexible schedule
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
- Wellness program
Work Location: In person
