RN-Clinical Care Coordinator

Job Description

Job Description

About the Role 
At T and N Services and Solutions, we embrace a “whole-person” approach to meet the diverse needs of our clients. The RN who operates as a Clinical Care Coordinator (CCC) will play a vital role in bridging physical health, behavioral health, and social determinants of health, ensuring seamless care coordination. This position involves collaboration with behavioral health clinicians and external providers, facilitating access to appropriate care levels, connecting clients to essential resources, and supporting their journey to recovery.

Key Responsibilities:

• Client Support: Conduct treatment planning, update diagnostic assessments, and ensure follow-ups to connect clients with healthcare and community resources.
• Care Navigation: Help clients navigate the healthcare system by connecting them with the right teams and resources at the right time. Support clients in becoming more active participants in their health and care.
• Documentation: Maintain comprehensive encounter notes detailing service purpose, actions taken, and results achieved.
• Crisis Intervention: Address client crises promptly and facilitate appropriate resolutions or escalations.
• Community Engagement: Identify and link clients to vital local resources, including housing, employment, education, and healthcare services.
• Multidisciplinary Collaboration: Bring together teams to address clients' complex health and care needs, especially for individuals with chronic or multiple long-term conditions.
• Team Collaboration: Act as a core member of the SUD treatment team, managing program operations, data tracking, and community resource coordination.
  

Qualifications:
Candidates must meet at least one of the following criteria to qualify as a CCC in Washington, DC:

• Licensed Professionals: Registered Nurse 

Work Schedule & Location

• 1-2 days a week on-site role at our DC outpatient clinic
• Clinic hours Monday–Friday, 8:30 AM–5:00 PM
• This roles works in office and in the community

Preferred Experience:

• Experience working with underserved populations in DC, particularly those with substance use disorders (SUD), opioid use disorders (OUD), or co-occurring mental and physical health conditions.
• Background in community-based treatment teams addressing social services needs such as housing, addiction recovery, and criminal justice involvement.
• Familiarity with diagnostic criteria (ASAM) and electronic medical systems (e.g., Credible, Insync, Data WITS).
• Previous work with dual-diagnosis populations (e.g., SMI/SED, IDD, and substance use).

Performance Expectations:

• Proactively manage a caseload by engaging with clients at least twice per week and tracking key health metrics.
• Ensure compliance with federal and district laws, licensing requirements, and scope of practice guidelines.
• Participate in discharge planning and facilitate seamless transitions to appropriate care levels or community services.
• Facilitate both group and one-on-one sessions.

Who Should Apply? 

Individuals with experience working in the community, such as home health or home care, with demonstrated familiarity in home visits, conducting assessments, and developing care plans, are highly encouraged to apply. 

Why Join Us? 
At T and N Services and Solutions, we are committed to fostering resilience, hope, and recovery for our clients. Join a collaborative and compassionate team that prioritizes holistic care and empowers individuals to achieve healthier, more fulfilling lives.