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Boston Health Care for the Homeless Program RN Care Coordinator, OneCare in Boston, Massachusetts

Who we are:

Since 1985, BHCHP’s mission has been to ensure unconditionally equitable and dignified access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. Over 12,000 homeless individuals are cared for by Boston Health Care for the Homeless Program each year. We are committed to ensuring that every one of these individuals has access to comprehensive health care, from preventative dental care to cancer treatment. Our clinicians, case managers, and behavioral health professionals work in more than 60 locations to serve some of our community’s most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity; centering dignity, compassion, mutual respect and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down barriers, including systemic racism which harms us all. We provide community-based health care services that are compassionate, dignified, and culturally appropriate, incorporating social determinants of health, with the goal of breaking down the physical and systemic barriers that our patients face.

Bilingual, Bicultural, LGBTQIA identifying, Black, Indigenous, and People of Color are encouraged to apply .

To learn more about working at BHCHP, watch our video Please Click Here ( .

Job Summary:

Hours:  Monday - Friday, 8:00 am-5:30 pm


Our dedicated clinical and non-clinical staff work hard to bring our mission alive. OneCare is a state initiative to improve health outcomes for patients under 65 eligible for both Medicare and Medicaid, many of whom have complex medical and behavioral health needs.

We’re looking for an RN to work on a small, supportive team providing care management services to OneCare patients. You’ll support linkages between enrolled patients, BHCHP medical teams and other providers. You’ll be trained by the Commonwealth Care Alliance to perform Minimum Data Set (MDS) assessments to create care plans customized to meet the needs of individual patients, as well as update these plans annually or when the patient has had a significant change in status. You will conduct outreach to support their progress toward better health outcomes. As these patients may be living in shelters or on the streets, you’ll need to be resourceful to connect with them.


  • Assumes responsibility for the coordination of care between BHCHP medical teams and the OneCare program for BHCHP patients who are enrolled in the OneCare Program.

  • Inputs authorizations for Durable Medical Equipment and other services (Home Health Aide, Homemaking, Skilled Nursing, Physical Therapy, and Personal Care Attendant) based on MDS assessment.

  • Conducts MDS assessments for patients enrolled in the OneCare program and create a plan of care with the patient to reach patient-centered outcomes.

  • Collaboratively participates as a member of the primary care team; communicates clearly and professionally with other members of the interdisciplinary team as well as with patients and caregivers.

  • Communicates with patients and/or caregivers including performing outreach as necessary in the greater Boston area for face-to- face contact to homes, hospitals, other facilities, etc. as needed to assess, build relationships, patient status, and identify new care needs.

  • Conduct in person and or telephonic follow up visit for patients who are discharged from an inpatient medical or psychiatric facility; advocates and discuss patient outcomes and trends to CCA (OneCare) insurance during monthly meetings.

  • Uses OneCare’s and BHCHP’s Electronic Medical Records (EMR) in a timely manner to note all patient interactions and outcomes accurately and efficiently.

  • Conforms to BHCHP standards of performance around patient rights, customer service, infection control, safety procedures and culturally competent care.

  • Remains flexible in duties as role expands and is available for assistance with other projects as needed.


  • Licensed as RN in Commonwealth of Massachusetts; 1- 2 years RN experience preferred. Previous community health center or primary care experience.

  • Strong medical and surgical assessment skills

  • Interest in working with disadvantaged groups; Demonstrated interest in public health, primary and preventive nursing and working with an under-served population

  • Understanding of substance abuse and mental health

  • Must be well organized, efficient and can work autonomously and within a team

  • Experience with documenting in EMRs; EPIC, Guiding Care, and ECW strongly preferred

  • Must be able to collaborate with multidisciplinary teams to achieve best patient care

  • Proficient with Microsoft suite and ability to adapt to technological changes

  • Timely and strong communication skills via phone, e-mail, and internal secured messaging systems; ability to prioritize and have attention to timetables to complete task

  • Willingness to travel to outreach/various sites; valid driver’s license and car required or strongly recommended, but not required to travel to multiple sites

    Compensation and Benefits

    The compensation starts at $35.22 and will increase based on years of experience .

    BHCHP full time employees are eligible for our competitive time off policy of 4 weeks’ vacation, health, dental and vision insurance, 403B retirement savings plan and employer retirement contribution, and pre-tax MBTA pass program with 40% discount. In addition, eligible employees will receive yearly increases, additional compensation of seven thousand five hundred dollars added to your base hiring rate for demonstrated bilingual proficiency and the opportunity to work with local hospitals and community health centers.

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

    As an Equal Opportunity Employer, BHCHP pledges not to discriminate against and encourages those from underrepresented and underserved backgrounds to apply, particularly Black, Indigenous, and People of Color (BIPOC), LGBTQIA identifying, first generation college students and adults without a college degree, Bilingual and Bicultural persons; and individuals from low economic backgrounds.

    Covid-19 Vaccination: For the protection of our workplace and patients, BHCHP requires all staff to be fully vaccinated against Covid-19. Proof of Covid-19 vaccination(s) is required for employment. All candidates offered employment will be given details about how to demonstrate receipt of vaccination.

Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.

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