Job Description
Job Description
Salary :
Registered Nurse, PSH
Reports To : Nurse Manager, PSH
Location : PSH Sites
Overview
The PSH Registered Nurse (RN) delivers trauma-informed, community-based nursing care to individuals residing in Permanent Supportive Housing (PSH) who experience chronic health conditions, behavioral health challenges, and complex social needs. Functioning as a nurse case manager, the PSH RN provides both direct clinical services and holistic care coordination to improve health outcomes and promote housing stability among a highly vulnerable population.
This field-based role combines patient assessment, chronic disease management, care planning, health education, and interdisciplinary collaboration across PSH sites. The PSH RN plays a critical role in advancing health equity, reducing avoidable emergency department use, and fostering trusting relationships with residents who may have experienced trauma, stigma, or discrimination in healthcare settings.
Duties and Responsibilities
Community-Based Clinical Care
- Conduct comprehensive nursing assessments in housing units, PSH clinics, or mobile settings.
- Administer prescribed medications, injections, and vaccines; monitor response and side effects.
- Provide wound care, diabetic foot checks, health screenings, and other routine nursing procedures.
- Perform health maintenance tasks (e.g., vitals, blood glucose checks, medication reconciliation).
- Implement safety plans and provide crisis de-escalation support in collaboration with behavioral health staff.
- Maintain timely, thorough, and accurate documentation in the Electronic Health Record (EHR).
- Adhere to nursing protocols, HIPAA standards, infection control practices, and regulatory guidelines.
Care Coordination and Navigation
Develop, implement, and monitor individualized care plans in collaboration with the resident, primary care, behavioral health, and support teams.Track follow-up needs, missed appointments, and care plan progress across multiple providers and systems.Facilitate access to specialty care, lab testing, MAT, behavioral health services, and community resources.Serve as a central clinical contact for residents, housing partners, and external providers.Support transitions of care from hospitals or emergency departments to PSH settings.Patient Education and Engagement
Educate residents on medication use, self-management strategies, and condition-specific topics (e.g., hypertension, diabetes, COPD).Apply harm reduction and motivational interviewing techniques to promote health behavior change and treatment engagement.Encourage residents participation in care decisions and foster trust through consistent, non-judgmental presence.Engage residents at risk of disengagement or non-adherence, adapting communication strategies to individual needs.Collaboration and Interdisciplinary Support
Participate in interdisciplinary case conferences, MAT team huddles, and PSH site check-ins.Collaborate with CHWs, BHCs, peer specialists, and housing staff to ensure coordinated care.Communicate changes in resident status to the care team and escalate urgent concerns appropriately.Provide clinical insight to housing teams and support trauma-informed responses to health-related tenant issues.Support incident tracking, health outcome monitoring, and program improvement efforts.Contribute to organizational performance goals and grant reporting metrics as needed.Support HHH Mission
Demonstrates a commitment to HHHs mission of promoting health, hope, and dignity for individuals experiencing homelessness through equitable and compassionate care.Upholds trauma-informed, culturally responsive, and patient-centered principles in all interactions, contributing to an inclusive and supportive environment for patients and team members.Actively contributes to a culture of collaboration, accountability, and innovation in service of our goal to eliminate health disparities and advance systems-level change.Minimum Qualifications
Current RN license in the State of Texas, in good standingAssociate or bachelors degree in nursing from an accredited programAt least 2 years of nursing experience, preferably in community health, primary care, or case management settingsProficiency in EHR systems (EPIC preferred) and clinical documentationStrong communication, organizational, and critical thinking skillsComfortable working in field-based, non-traditional care environmentsPreferred Qualifications
Experience working with people experiencing homelessness, behavioral health conditions, or substance use disordersFamiliarity with harm reduction, motivational interviewing, and trauma-informed care modelsExperience in a Federally Qualified Health Center (FQHC) or outreach settingBilingual in English and SpanishHHH values lived experience as an essential form of expertise. Individuals who have experienced homelessness, housing instability, or other barriers to healthcare access are strongly encouraged to apply.