Hamilton County Health Link RN Care Coordinator - Health Link Children and Youth or Adult

Job Requirements:  Associate/Bachelor of Nursing degree with course work or experience in the areas of cultural diversity, human development, primary care, etiology and treatment of mental illness, alcohol and drug abuse, physical and sexual abuse, suicide, and intellectual developmental delays. Must have Registered Nurse license valid in Tennessee.

Experience:  Associate/Bachelor degree from an accredited College/University. Experience in psychiatric nursing and acute care preferred. Must have the ability to present professionally, work within a team format, and have the mental ability to exercise sound, clinical judgment under pressure.  Must have the ability to communicate effectively (both oral and written) and possess good time management and organizational skills. Basic computer skills required; experience with electronic medical record (EMR) preferred. Experience with interdisciplinary collaboration and care coordination preferred.

Physical: Minimal exposure to biological hazards. Frequent exposure to unpleasant odors. Hearing of normal and soft tones. Close eye work. Lifting up to 50lbs. Pushing/pulling up to 250lbs. Frequent sitting, standing, walking, bending, stooping, and reaching. Required to be certified in and adequately implement verbal and physical de-escalation techniques that include a wide range of bodily movements including but not limited to grasping, holding another person, running, and walking. Physical de-escalation techniques will only be implemented at Helen Ross McNabb Center facilities, and not in community settings.



Job Summary:  The Health Link RN Care Coordinator is responsible for the clinical oversight of a minimum caseload of 250 patients. The HL RN Care Coordinator functions as the primary leader of all treatment teams, maintains contact with all external providers, coordinates medical care between providers (including external medical providers, specialists, pharmacy) and delegates care coordination, as clinically appropriate, to care coordinators. In addition, the RN HL Care Coordinator oversees the quality of HL services and ensures that quality metrics are being met. He/she will be responsible for providing health promotion, prevention and wellness management to patients. This position is also responsible for triaging medical phone calls, may require face to face triage as necessary to divert from ER, and is responsible for monitoring and coordinating post hospital care. The HL RN Care Coordinator will embrace the key values of clinical services: empowerment, normalization, rehabilitation, and continuity of care, as well as to adhere to HRMC policy and procedures.


  • Provides clinical leadership to the HL team
  • Provides advocacy, linkage, and referral services as needed
  • Maintains appropriate chart records and completes all documentation in a timely manner
  • Initiates and updates comprehensive care management plans
  • Interfaces with MCOs, families, medical providers, courts, school systems and other agencies to coordinate care
  • Provides health education and prevention for chronic health conditions
  • Promotes health behaviors and self care
  • Serves as a clinical specialist for medication management issues
  • Leads weekly treatment team meetings
  • Participates in care planning with medical providers as needed
  • Triages nurse calls and performs in person assessments as needed
  • Upholds center policy and procedures, and CARF standards



This job description is not intended to be all-inclusive; and employee will also perform other reasonably related job responsibilities as assigned by immediate supervisor. This organization reserves the right to revise or change job duties as the need arises.  Moreover, management reserves the right to change job descriptions, job duties, or working schedules based on their duty to accommodate individuals with disabilities. This job description does not constitute a written or implied contract of employment.

Quality Care

a)      Provides care coordination for patients with a mental health diagnosis and co-occurring chronic health condition.

b)      Provides monthly quality coordination contacts for patients in the Health Link program.

c)       RN Care Coordinator will provide ongoing daily support to all care coordinators in relation to any patient’s needs, as part of a multidisciplinary team.

d)      RN Care Coordinator will delegate and assist with the facilitation of care coordination between external medical provider, behavioral health provider, pharmacy, specialists, and / or guardians regarding health needs of the patient.

e)      RN Care Coordinator will provide health education, promotion, and prevention promote with the patient and/or family.

f)       RN Care Coordinator will provide crisis intervention and emergency services as needed.

g)      Ensures all family and client participation in treatment planning as evidence by signatures on care plans.

h)      Leads treatment team meetings with HL care coordinator and HL administrative supervisor.

i)        Responds to all flags, e-mails, and voicemails within 2 business days.

j)        Manages all Nurse Line calls, injections, PA’s, and refill requests.

k)      Returns all voicemails in a timely manner.

l)        Initiates and updates care plans and discharge planning.



a)      Completes all required clinical documentation in accordance with Center Policy and Procedure and funding source guidelines.

b)      Completes and signs EMR documentation within two business days of encounter.

c)       Ensures that all patients have an up to date ROI, HL consent form, and comprehensive care management plan.

d)      Monitors and ensures that all core quality and efficiency metrics are being met and documented.

e)      Create and coordinate treatment interventions that are reflected in HL documentation based on the care plan goals.

f)       Attends supervision with HL administrative supervisor.


Professionalism/Professional Development

a)      Interacts professionally with other employees, patients, and community organizations.

b)      Exhibits accountability for assigned responsibilities.

c)       Works independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations.

d)      Attends and engages in staff development activities as requested by supervisor.

e)      Is expected to have regular and predictable attendance and the ability to work cooperatively with others.

f)       Accepts additional assignments and/or changes in assignment and/or work.

g)      Maintains professional, respectful communication with co-workers, patients, and referral sources even when conflict arises.

h)      Promotes an environment in which the culture and spiritual beliefs of the individual are respected.