Careers At Legacy Community Health Services

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RN - Nurse Care Coordinator-Montrose Clinic

Department: Nursing
Location: Houston, TX

Legacy Community Health is a premium, Federally Qualified Health Center (FQHC) that provides comprehensive care to community members regardless of their ability to pay. Our goal is to treat the entire patient while improving their overall wellness and quality of life, in addition to providing free pregnancy tests, HIV/AIDS screening. At Legacy, we empower patients to lead better lives by promoting healthy behaviors and offering resources such as literacy classes, family planning services, and nutrition and weight management information.

Our roots began in 1981 as the Montrose Clinic, with specialization in HIV education, testing, and treatment. Since then, the agency has expanded to 10 clinics in Houston, one in Baytown, two in Beaumont, and one in Deer Park with extensive services that include: Adult primary care, HIV/AIDS care, pediatrics, OB/GYN and maternity, dental, vision and behavioral health. We also service students within KIPP and YES Prep schools. Legacy is committed to driving healthy change in our communities.

Job Description

The Care Coordinator is an integral member of the multidisciplinary team. The Care Coordinatorís primary responsibility is to coordinate the health and wellness of a panel of designated patients within high-risk groups. Utilizing a collaborative approach, the Care Coordinator will assess, plan, implement, monitor and evaluate the options and services required to meet an individualís health needs. The Care Coordinator collaborates with the healthcare team, to establish care and allocate resources.

Essential Functions

  • Actively manages care coordination efforts, , for an assigned panel of high-risk patients to ensure care delivery as it relates to pre-visit preparation, referrals to specialists, transitions of care, ancillary testing, acquisition of medical equipment and other services, as needed.
  • Actively manages desired communication on behalf of patient through communication and appropriate documentation in patientís charge.
  • Collaborate with the patient and patientís care team to develop an individualized treatment care plans documented in patients EHR.
  • Identify barriers and resulting opportunities for intervention and serves to facilitate resources as needed and documents in chart to demonstrate task/needs assessment and completion
  • Provides the essential oversight to address and assure required services are attained such as preventive and disease management screening and/or follow up
  • Communicate directly with patients to set care goals and provide the tools for self-management  as evidenced by chart documentation.
  • Performs intermittent assessments as established by protocols and provides follow up with appropriate providers
  • Identifies and performs appropriate intervention when assessment is not on target based on pre-defined goals through active patient engagement
  • Oversees patientís needs for transitioning care like, visits to hospital/ER a specialty physicians, or by another health care provider
  • Maintain collegial relationships with community resource agencies and connect patients to the appropriate resources as needed
  • Performs other duties as assigned.


Education & Training Requirements

  • State Board recognized nursing education.
  • State of Texas Registered Nursing License.
  • BSN Preferred.

Work Experience

  • Minimum three (3) years, home care/primary care clinical experience is highly desirable.
  • Experience in provision of care management/care coordination REQUIRED!
  • Must be able to manage multiple deadlines and prioritize
  • Adept in decision making responsibilities
  • Proficient in English: Speaking, reading, writing
  • Supports practice mission and goals
  • Bilingual Spanish preferred
  • CCM or CCTM certification preferred


  • 9 Holiday + 1 Floating Holiday
  • PTO
  • 403b Retirement Plan
  • Medical / Vision / Dental (if eligible)

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