Registered Nurse - Transitional Care

About the Coalition

The mission of the Colorado Coalition for the Homeless is to work collaboratively toward the prevention of homelessness and the creation of lasting solutions for families, children, and individuals who are experiencing or at-risk of homelessness throughout Colorado. The Coalition advocates for and provides a continuum of housing and a variety of services to improve the health, well-being, and stability of those it serves.

Our Philosophy of Service

We believe all people have the right to adequate housing and health care. We work to remove the barriers that restrict access to these rights. Society benefits when adequate housing and healthcare are available to everyone. We create lasting solutions to homelessness by:

• Honoring the inherent dignity of those we serve, affirming their capabilities, and fostering their hope that a better life is possible;
• Building strong, caring, and trauma-informed communities through the integration of housing, health care, and supportive services;
• Advocating for social and racial equity, inclusion, and diversity and challenging the status quo in partnership with our workforce members and those we serve;
• Achieving excellence through continuous quality assurance, innovation, and professional development;
• Using resources judiciously and effectively.

About the Role

The Transitional Care Management (TCM) Registered Nurse delivers high-quality, compassionate nursing care to people experiencing homelessness or housing instability. The TCM RN supports patients as they transition between hospitals, emergency departments, skilled nursing facilities, outpatient providers, and community settings. Working collaboratively within the Integrated Health Services (IHS) team and with partner hospitals, the TCM RN improves discharge outcomes, expands access to hospital follow-up visits at CCH, reduces avoidable readmissions, and improves continuity of care.

The TCM RN coordinates health care transitions for CCH patients; assesses patient needs and goals, connects patients to appropriate resources; and performs both independent and delegated nursing duties. The TCM RN also provides nursing and triage support to the CCH Respite team and on-site nursing support at Stout Street Health Center (SSHC) and affiliated satellite clinics as needed.

Responsibilities

• Provide skilled nursing care according to community standards and CCH protocols.
• Deliver comprehensive patient-centered care, addressing physical, emotional, and social needs.
• Conduct rapid and accurate triage assessments, providing appropriate care recommendations.
• Educate patients on managing chronic and acute health conditions, including diabetes, hypertension, nutrition, wound care, infectious disease, gender-affirming care, family planning, and disease prevention.
• Administer medications safely and effectively as per protocols.
• Collaborate closely with a multidisciplinary healthcare team to ensure holistic patient care.
• Facilitate access to internal programs such as health outreach and housing support services.
• Oversee care for patients with transitional, chronic, and complex health conditions.
• Mentor new nurses and nursing students, enhancing their clinical skills and confidence.
• Document all patient interactions and care activities in the electronic health record (EHR).
• Engage in continuous professional development and participate in quality improvement initiatives.
• Provide patient-centered care within an integrated, trauma-informed, culturally-aware, harm-reduction model.
• Perform quick and accurate triage assessments with appropriate recommendations of care as outlined in SSHC nursing protocols via telephone or in-person.
• Empower patients by providing health education and information.
• Collaborate with other members of the multi-disciplinary healthcare team and coordinate care with internal programs.
• As a member of an OBH licensed Substance Use Disorder (SUD) treatment team, provide treatment services such as case management, crisis services, initial intake program screenings, individual medication-assisted treatment (MAT) counseling, and administering scales to assess withdrawal.
• Provide nursing services as needed to all CCH programs and facilities.
• Serve as a preceptor to new nurses and nursing students.
• Participate in team-based or interdisciplinary quality improvement initiatives.
• Attend required disciplinary, inter-disciplinary, suite, quality improvement, and all-staff meetings.
• Work day, evening, or weekend clinic shifts as scheduled or appropriate.
• Ensure timely, accurate documentation of all clinical services, communications, and patient records in the EHR.
• Monitor EHR inboxes for CCH patients who have experienced an Emergency Room or hospital admission and assist them with PCP follow-up planning.
• Assist with medical case management of patients with high ED utilization, with the goal of reducing hospital admissions through robust primary care.
• Perform other duties as assigned.

Requirements

• Associate’s, Bachelor’s, or Master’s degree in Nursing from an accredited college or university.
• Current Registered Nurse licensure in the State of Colorado.
• Basic Life Support certification.
• Preferred experience in ambulatory, public, community, mental health, or emergency nursing.
• Familiarity with diverse or marginalized communities is highly desirable.
• Bilingual preferred.

Work Location and Schedule

This position is based at Stout Street Health Center. The role is eligible for a hybrid work arrangement, which may include a combination of remote, onsite, and community-based work. Duties that can be performed effectively offsite, including telephone or virtual patient outreach, care coordination, documentation, and team collaboration, may be performed remotely with supervisor approval. Regular onsite and community-based work is required for direct patient care, in-person meetings, training, coverage, and other operational needs.

The specific hybrid schedule will be established with the supervisor and subject to change based on patient, program, team, and operational needs, up to and including a return to fully onsite work. Hybrid work at CCH is a flexible arrangement, not a guarantee.

To support safe and effective remote work, this role requires reliable internet access, a private and confidential workspace suitable for handling protected health information (PHI), and compliance with CCH privacy, security, remote-work, and HIPAA policies. CCH may adjust hybrid arrangements based on operational needs, patient care requirements, or program changes.

Work is performed at CCH clinical settings, in the field (including hospitals, shelters, and environments not meant for human habitation), and, when authorized, remotely from an approved workspace. The allocation of onsite, remote, and field-based work may vary at CCH’s discretion based on patient, team, and operational needs.

Schedule options may include five 8-hour shifts or four 10-hour shifts, based on supervisor approval and program needs. All hours worked, whether remote or onsite, must be recorded accurately in the CCH timekeeping system in accordance with CCH policy and applicable wage-and-hour law.

Benefits

We offer a full suite of benefits for our eligible employees and their dependents. We’re proud to offer same- and opposite-sex domestic partner coverage.

• Health Insurance - HMO or PPO
• Dental plans, vision insurance, flexible spending accounts, supplemental life insurance
• Company-paid basic life and AD&D insurance coverage
• Employee Assistance Program
• 403(b) retirement savings matching
• Extensive paid time-off, including holidays, sick leave, and vacation

The effective date for your benefits will be the first of the month following your date of hire.