Nurse Care Coordinator - Northern VT OP


The RN Care Coordinator is responsible for providing care coordination and case management services, following established standards and practices within the scope of their licensure, to Phoenix House Health & Recovery Solutions patients receiving Medication for Opiate Use Disorder (MOUD), formally referred to as Medication Assisted Therapy.

The RN Care Coordinator at Phoenix House Health & Recovery Solutions is accountable to:

  • Managing their day-day clinical, administrative, operational and fiscal responsibility as it relates to patient care
  • Ensuring uniform implementation and execution of Phoenix House policies, procedures and protocols
  • Actively assisting the Phoenix House Executive Leadership Team with the administration of Phoenix House New England'sstrategic plans and goals


  1. Health Home Service/Activities:  Team with a Clinical Care Coordinator to provide health home service to a panel of 100 MOUD patients (per Full-Time Equivalent of care coordination).  Minimum requirement is an "auditable record of at least one health home service per patient each month."  Establish mapping for the six health home services in each clinical record system that the MOUD team can use.
  2. Comprehensive Care Management:  Activities undertaken to identify patients for Medication for Opiate Use Disorder, conduct initial assessments, and formulate individual plans of care.  Also includes activities related to managing and improving the care of the patient population across health, substance abuse and mental health treatment, and social service providers.
    • Identification of potential MOUD patients via referrals, prior authorizations, VT Chronic Care Initiative (VCCI) risk stratification, claims and utilization data, judicial referrals for treatment, and outreach to patients lost to contact
    • Assessment of preliminary services needs; treatment plan development; including client goals
    • Assignment of health team roles and responsibilities
    • Developing treatment guidelines and protocols for health teams to use in specific practice settings (primary care, specialty care) for transitions of care, identified health conditions (e.g. opioid dependence with depression or chronic pain), and prevention and management of substance relapse
    • Monitor MOUD patient's health status, treatment progress, service use to improve care and address gaps in care
    • Develop and use data to assess use of care guidelines in practice settings, patient outcomes, and patient experience of care
    • Design and implement quality improvement activities to improve the provision of care (learning collaborative, PDSA cycles)
  3. Care Coordination:  Implementation of individual plans of care (with active patient involvement) through appropriate linkages, referrals, coordination and follow-up as needed to services and supports across treatment and human services settings and providers.  The goal is to assure that all services are coordinated across provider settings, which may include medical, social, mental health, substance, corrections, educational, and vocational services.
    • Appointment scheduling, outreach to support attendance at scheduled treatment and human services appointments
    • Conducting referrals and follow-up monitoring, participating in discharge planning from hospital, residential, and corrections
    • Communicating with other providers and family members
    • Monitoring treatment progress and implementation of the individual care plan
    • Case management necessary for individuals to access medical, social, vocational, educational, substance abuse and/or mental health treatment supports, and community based recovery services
    • Coordinating with other providers to monitor individual's health status and participation in treatment
    • Assessing medication adherence and calculating medication possession rates
    • Identification of all medications being prescribed, communication with prescribers, and medication reconciliation
    • Access to and assistance in maintaining safe and affordable housing
    • Conducting outreach to family members and significant others in order to maintain individual's connection to services and expand their social network
  4. Health Promotion:  Activities that promote patient activation and empowerment for shared decision-making in treatment, healthy behaviors, and self-management of health, mental health, and substance use conditions.
    • Providing health education specific to a patient's chronic conditions
    • Providing of health education specific to opioid dependence and treatment options
    • Identifying health and life goals and development of self-management plans with the patient
    • Motivational interviewing and other behavioral techniques to engage patients in healthy lifestyles and reduce substance use
    • Supports for management of chronic pain
    • Supports for smoking cessation and reduction of use of alcohol and other drugs
    • Providing health promoting lifestyle interventions including but not limited to nutritional counseling, obesity reduction, and increasing physical activity
    • Providing support to develop skills for emotional regulation and parenting skills
    • Providing support for improving social networks
  5. Comprehensive Transitional Care:  Care coordination focused on planned, seamless transitions of care through streamlining the movement of patients from one treatment setting to another, between levels of care, and between health and specialty MH/SA service providers.  Goals are to reduce hospital readmissions, facilitate timely development of community placements, and coordinate the sharing of necessary treatment information among providers.
    • Developing and maintaing collaborative relationships between health home providers and other entities such as hospital emergency departments, hospital discharge departments, corrections, probation and parole, residential treatment programs, primary care providers, and specialty Mental Health/Substance Use treatment services
    • Developing and implementing referral protocols including standardized clinical treatment information on electronic and paper Continuity of Care Documents (CCD)
    • Developing and using data to identify MOUD clients with patterns of frequent ED, Hospital, or other relapse-related services utilization and planning systemic changes to reduce use of acute care services
  6. Individual and Family Support:  Assisting individuals to fully participate in treatment, reducing barriers to access to care, supporting age and gender appropriate adult role functioning, and promoting recovery.
    • Advocacy
    • Assessing individual and family strengths and needs
    • Providing outreach and supportive counseling to key caregivers
    • Providing information about services and formal and informal resources, and education about health conditions and recommended treatments
    • Providing assistance with navigating the health and human services systems
    • Providing assistance with obtaining and adhering to prescribed treatments including medications
    • Facilitating participation in ongoing development and revisions to individual plan of care
  7. Referral to Community & Social Support Services:  Assisting clients, obtain and maintain eligibility for formal supports and entitlements (e.g. health care, income support, housing, legal services) and to participate in informal resources to promote community participation and well-being.
    • Developing and maintaining up-to-date local information about formal and informal resources beyond those covered in the Medicaid plan, including peer and community-based programs
    • Assisting and supporting access to community resources based on individual patient needs and goals
    • Assisting patients, obtain and maintain eligibility for income support, health insurance, housing subsidies, and food assistance
    • Providing information and supporting participation in vocational and employment services to promote economic self-sufficiency
  8. Health Home Quality Measures:  Tracking and reporting Health Home Quality Measures.  The program requires that Health Homes select from established HEDIS measures to measure outcomes and quality.
    • Measure 1: Self-Management for any chronic condition (including opiate dependence)
    • Measure 2: Adult Body Mass Index (BMI)
    • Measure 3: Age and gender appropriate health screenings
    • Measure 4: Screening for Clinical Depression and Follow-Up Plan - Percent screened for clinical depression using standardized tool with follow up documentation
    • Measure 5: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
    • Measure 6: Alcohol Misuse Screening - Annual screening with AUDIT-C and documentation
    • Measure 7: Tobacco Cessation Screening - Receipt of advice to quit smoking
    • Measure 8: Tobacco Cessation Screening - Receipt of information on smoking cessation medications Measure 9: Care Transition - Transition Record Transmitted to Health Care Professional
    • Measure 10: Care Transition - Transition Records - receipt of transition record at time of discharge with specified elements
    • Measure 11: Care Treatments - Receipt of reconciled medication list


  • Be responsible for creating a safe and accident-free environment. Safety comes first over all responsibilities.
  • Effectively communicates with the patient and the family/support system about the treatment plan, resources and required follow up care.
  • Utilizes the Phoenix House of New England's electronic health record by appropriately documenting all patient interactions ensuring to include all necessary documentation and coding is comprehensive and complete to support both quality of care and revenue cycle.
  • Actively participates in program committees and maintains both a collegial and independent relationship with members of the medical staff and clinical/administrative team members.
  • Demonstrates support of and assists with the execution of cost saving process improvement initiatives.
  • Partners with other programs and team members to ensure efficient flow of patients.
  • Takes pride in ones' environment by helping to maintain an organized, uncluttered and clean workplace.
  • Partners with and reports any programmatic safety concerns through on-site observation, incident report generation and/or review, root cause analysis, best practice review and implementation training to improve programmatic and organizational standards.
  • Partners with and report quality improvement needs through review of Patient Satisfaction Survey reviews and other identified and developed tools.
  • Consult with Directors related to implementing and maintaining structure & accountability related to organizational goals, values and mission.
  • Assess and report programmatic implementation of policies, procedures and best practices.
  • Participate and/or Facilitate necessary trainings related to identified programmatic and/or organizational needs.
  • Support accurate, timely, legible clinical & clerical notes.  Document developments and important events in accordance with clinical policies for reporting and record keeping.  Use Phoenix House systems, including Electronic Health Record (EHR), effectively and appropriately.
  • Complete 30, 60, 90-day Self -performance supportive review documentation as required.
  • Complete all necessary DATIS files, timecards and e-learning Relias requirements in a timely fashion.
  • Work cooperatively with supervisor and team members.
  • Complete all notes in a timely manner.
  • Meet with supervisor on a regular basis.
  • Serve as a rolemodel through positive, appropriate conduct and participation in special agency events.  Project a good image to the public.
  • Dress in a professional manner.
  • Perform other duties as assigned by direct supervisor or designee.


To perform this position successfully, you must be able to perform each essential duty and responsibility satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.  The requirements listed below are representative of the knowledge, skill and/or ability required. 

§  Use AIDET during patient encounters: Acknowledge, Introduce, Duration, Explanation, Thank-You

§  Find a way to say YES to patients/customers and co-workers or be responsible for finding someone who can assist if I am unable to in that moment.

§  Excellent communication and collaboration skills

§  Proven critical thinking and problem solving skills

§  Ability to establish a therapeutic relationship with patients and support resources (family or friends)

§  Strong organizational skills with ability to manage numerous cases effectively

§  Strong team building skills

§  Ability to effectively use computer software; web-based applications for assessing and managing addiction

§  Ability to provide self-management support

§  Skilled at process and clinical outcomes improvement using quality improvement methodologies, including tracking and reporting measures

§  Knowledge of the treatment of co-occurring populations and MOUD as appropriate.

§  Extensive knowledge of the daily operations of a not-for-profit substance use and mental health disorder health facility.

§  Ability to prioritize conflicting demands/expectations as well as to multi-task effectively for sustained periods of time.

§  Ability to apply organizational management skills and maintain self-discipline.

§  Ability to collaborate and build successful relationships with others to ensure objectives and goals are met.

§  Communication skills both written and verbal as well as the understanding of the principals of communication in multiple directions, vertically, horizontally and laterally.

§  Problem solving skills with a collaborative mind-set.

§  Knowledge of Continuous Quality Improvement process and Performance Improvement program design and implementation.

§  Proficiency in using Phoenix House systems, including Electronic Health Record system to document notes and activities as necessary is expected within 30 days of employment.

§  Skill in representing the organization internally and externally.

§  Ability to provide support and direction to program staff, volunteers and interns.

§  The ability to be forthcoming with information and/or personal challenges to ensure the facility Program Director and Vice President has an accurate awareness of any issues that may impact him/her or his/her program as well as his/her staff or other members of PH.

§  Be Accountable and Dependable.

§  Maintain objectivity towards all patients and make decisions based on accurate information.

§  Utilize Trauma Informed best practices with patients and staff to promote effective and safe coping skills and self-


§  Demonstrate appropriate boundaries between self and staff/patients.

§  Knowledge of rules and regulations related to HIPPA and 42 CFR Part 2.

§  Ability to comply with internal, local, state, and federal regulations and policies.

§  Ability to promote and demonstrate "Every Time Behaviors" Teamwork model.

§  Ability to promote and demonstrate Phoenix House's ICARE4 core values (Integrity, Collaboration, Accountability, Respect, Excellence, Forward Thinking) through work ethic, compliance, and attitude:

-  Trustworthiness

-  Morale

-  Willingness to Help

-  Optimism

-  Knowledge


Graduate of an Accredited School of Nursing with a BSN required. MSN or other relevant Master's degree preferred.



Valid VT RN license required.  Case Management certification preferred.  Valid Driver's License and automobile insurance required.


The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties and responsibilities of this position.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.

REGULARLY REQUIRED:  to sit, use hands to finger, handle or feel objects, tools or controls; reach with hands and arms, and talk or hear.

OCCASIONALLY REQUIRED:  to stand, walk, stoop, kneel or crouch and lift and/or move up to 10 pounds


The work environment characteristics described here are representative of those an employee encounters while performing the essential duties and responsibilities of this position.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and responsibilities.

The work environment is that of a substance use and mental health disorder treatment milieu which may include:

§  Exposure to and contact with patients under a variety of circumstances whose exposure elements may include infection with Hepatitis B, C, HIV, TB, or other Infectious and contagious Diseases.

§  Exposure to patients with co-occurring mental health issues.

§  Weekend and holiday hours

§  Business-related travel


First, second, and/or holiday shifts may be required.

Phoenix House is an Equal Opportunity Employer providing equality of opportunity to all who are protected against discrimination by law, regulation or executive order, including veterans and individuals with disabilities. EEO is the Law: Applicants and employees are protected under Federal law from discrimination. Click to learn more.