Clinical Nurse Coordinator- FT

WILLIAMSPORT, PA 17701

• Position Type: Full Time
• Education Level: 4 Year Degree

The Clinical Nurse Coordinator provides nursing leadership, assessment, care coordination and staff education to improve the health and well-being of individuals supported by Hope. The position leads early identification of health risks, safe hospital transitions, staff competency development and evaluation of health outcomes. The nurse partners with individuals, families or authorized representatives, treating providers, program leaders, supports coordinators and Quality Management while respecting individual choice, privacy and nursing scope of practice.

Primary responsibilities focus on Residential services. Support to Life Sharing and Supportive Living, Choice and other programs as assigned by the Chief Operating Officer based on clinical need, program requirements and available capacity.

ESSENTIAL FUNCTIONS

Must be able to read, write, comprehend information, perform moderately difficult math, and demonstrate advanced communication skills. Responsibilities include traveling to assigned sites, conducting nursing assessments and authorized interventions, providing education, maintaining accurate electronic records, communicating effectively, and performing safety and crisis intervention skills as needed. Must follow confidentiality, professional boundaries, person-centered practices, individual support plans, safe handling procedures, and agency safety protocols. Must maintain required competencies and perform duties consistent with licensure and training. A valid driver’s license, personal vehicle for work-related travel, and insurability under Hope’s insurance carrier are required. Essential functions may be performed with or without reasonable accommodation.

SPECIFIC DUTIES (include but are not limited to):

Clinical assessment and Nursing Support

• Assess changes in health status, identify nursing needs and communicate findings and recommendations to treating providers and support teams.
• Perform authorized nursing interventions within current competency, applicable orders, agency policy and available resources. Document assessments, interventions, communications and follow-up in the designated clinical record.
• Arrange further evaluation or emergency escalation when indicated.

Health Risk Screening

• Complete and maintain applicable Health Risk Screening Tool (HRST) rater and clinical reviewer training and qualifications. Coordinate the HRST workflow; conduct required nursing reviews following applicable timelines and changes in condition; document review and sign-off; and track follow-up on identified risks.
• Work with assigned raters and program leaders to address overdue reviews and unresolved concerns.

Hospital Transitions

Lead Hospital Transition Planning Committee meetings and provide clinical guidance to support safe transitions from hospital to home.

• Assist the residential team in identifying changes in medical needs, reviewing discharge instructions, and determining necessary clinical supports.
• Provide or arrange staff education related to new medical needs or interventions, as appropriate.
• Offer nursing consultation on clinical concerns and recommend follow-up or escalation when indicated.

The residential team retains responsibility for discharge coordination and implementation, including hospital communication, medications, equipment, supplies, staffing, follow-up appointments, and documentation. Treating clinicians determine medical readiness for discharge.

Referrals and Admissions

• Participate in the referral committee.
• Assess anticipated clinical needs, medication complexity, equipment, staff competency and available supports.
• Provide a documented recommendation identifying resources, training and unresolved clinical concerns before admission or service expansion.

Diabetes and Medication Safety

• Serve as a clinical resource to the Training Department on diabetes care, insulin administration, medication safety, and individual-specific medical needs.
• Pursue qualifications to provide required annual insulin administration training, as agreed with the Chief Operating Officer, and deliver this training once applicable instructor qualifications and program approval requirements are met.
• Collaborate with medication administration trainers, pharmacy, and program leaders to address medication-related concerns and reduce errors.

The Training Department retains responsibility for coordinating required training, delivering the medication administration course, and maintaining training and competency records.

Health Improvement and Wellness

• Use HRST findings and other clinical data to identify health changes and coordinate individualized follow-up with the person and care team.
• Lead prevention and education addressing aspiration, bowel complications, dehydration, seizures, infection and sepsis, falls and other significant risks.
• Develop and evaluate accessible, person-centered wellness education and activities. Maintain evidence of participation, adaptations, outcomes and improvement supporting applicable ODP Performance-Based Contracting health and wellness standards.

Staff Education and Competency

• Develop practical education on recognizing changes in condition, individual-specific interventions, medical devices, infection prevention and emergency response.
• Evaluate and document competency where applicable.
• Coordinate training needs with program leaders and Human Resources as warranted.

Quality Review and Reporting

• Partner with Quality Management to review clinical aspects of health incidents, medication errors, falls, hospital use and recurring concerns.
• Recommend corrective actions, identify responsible parties with program leadership and evaluate effectiveness.
• Maintain useful clinical dashboards and provide quarterly reports to the Chief Operating Officer, with prompt reporting of urgent risks.

Clinical Policies and Collaboration

• Participate in the policy subcommittee.
• Develop and recommend clinical policies, procedures and escalation guidance for approval.
• Support regulatory preparation and implementation of clinical requirements.
• Provide consultation to program leaders and coordinate with external nursing, medical, pharmacy, hospice and other providers to maintain clear responsibilities and continuity of care.

Clinical Authority and Accountability

• The nurse provides professional nursing direction within the position’s assigned responsibilities and makes clinical recommendations based on assessment and available information. The nurse identifies required clinical training and verifies applicable competency before recommending staff readiness for an assigned intervention. When an intervention cannot be performed safely within available orders, competency or resources, the nurse directs immediate clinical escalation and promptly notifies the responsible program leader and Chief Operating Officer.

• The nurse escalates unresolved health risks, unmet clinical recommendations and barriers to safe transitions to the Chief Operating Officer. Program leaders remain accountable for staffing, scheduling and implementation of operational actions. Treating providers retain prescribing and medical treatment responsibilities; Quality Management retains its assigned investigation and incident management responsibilities.

Schedule and Occasional After-Hours Response

The normal work schedule is established with the Chief Operating Officer and may be adjusted for planned site visits, training and hospital transitions. Regular travel among assigned sites is required. Remote work requires approval and must support timely completion of on-site responsibilities.

Occasional after-hours telephone consultation or in-person nursing response may be requested when clinically appropriate.

After-Hours Nursing Support: A stipend will be provided for requested after-hours residential nursing care, subject to the nurse’s availability. Requests will be coordinated through the Chief Operating Officer and/or Director of Residential Services.

HOURS: 40 hours weekly, exempt position; Hybrid Office environment (remote and on-site as required)

IMMEDIATE SUPERVISOR: Chief Operating Officer

POSITIONS SUPERVISED: None

Qualifications

• Experience supporting individuals with intellectual and developmental disabilities, community health, long-term care or individuals with complex health needs.
• Experience with clinical program development, staff education, quality improvement, HRST and Pennsylvania ODP service requirements.
• Certified Diabetes Care and Education Specialist (CDCES) credential or relevant diabetes education experience. Required program approvals and instructor qualifications must be verified separately before providing regulated staff training.