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Services for the UnderServed, Inc (SUS) Registered Nurse in New York, New York

The Registered Nurse (RN) is responsible for the oversight of medical treatment to a new funded innovative care transition team Pathway Home that serves individuals transitioning to the community from a higher level of care. The RN serves as a liaison between participants and their medical providers to ensure that participants are linked and engaged with identified community providers and that their support network is sufficient to meet their needs. In service delivery, the RN utilizes the nursing approach of assessment, planning, intervention, implementation and evaluation to assist individuals in their achievement of health, rehabilitation and recovery goals. The RN is an advocate for the health needs of participants. The role will require some on call coverage.

Job Responsibilities:

  • Develop, implement and maintain Pathway Home program nursing standards.

  • Collaborate with the Program Director on the development of policies and procedures and the identification of essential resources to deliver nursing services.

  • Conduct health assessments to determine participants’ immediate medical needs and readiness to receive services.

  • Develop, or consult and coordinate with the team to develop, plans to address participant health needs.

  • Collaborate with outside medical and behavioral health providers to schedule appointments and coordinate care.

  • Provide direct individual and group services including: service planning and coordination; support with obtaining housing; developing social connections; strengthening family and other natural supports; family conferences and psycho-education to support network members; developing living skills and obtaining necessary resources; entitlement and financial management; empowerment and self-help; wellness self-management with a focus on developing coping skills; short-term counseling; safety planning; travel training; and support with medications.

  • Oversee the general healthcare of participants including connecting participants with medical and dental providers, coordinating follow up appointments and ensuring that medication and treatment needs are being met considering prescribed treatment and participants’ expressed wishes.

  • Accompany participants to medical appointments as needed.

  • Provide health education, support on how to access and utilize community healthcare services, and connections to primary, specialty and preventive care.

  • Advise participants on holistic health maintenance and disease prevention including nutrition, diet and physical activity.

  • Monitor, record, and report symptoms or changes in participants’ conditions and record medical information and vital signs.

  • Serve as a resource and provide consultation to team on participant medical concerns; provide nursing perspective in the development and implementation of service plans.

  • Participates at team and administrative meetings and provides nursing input on the development and implementation of treatment/service plans.

  • Provides information and collaborates with other clinical staff, supportive housing staff, and administrators on nursing standards of practice and procedures.

  • Provides health education for participants and their families for specific medical needs, preventative care, and how to access and utilize healthcare services in the community.

  • Participates in risk management and quality assurance concerning health related issues.

  • Provide 24 hour crisis intervention services on a rotating basis, including referrals to respite and other resources.

  • Performs other related duties as assigned.

  • This position requires travel throughout the five boroughs of New York City.

  • License and current registration to practice as a registered nurse in New York State

  • Prefer at least one- year post RN licensure clinical nursing experience working with individuals with behavioral health needs.

Join a team of employees who cares about the wellbeing of others. We believe in fostering a culture built on our core values: respect, integrity, support, maximizing individual potential and continuous quality improvement.

S:US is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. S:US is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities, including allowance of the use of services animals. To request reasonable accommodation or if you believe such a request was improperly handled or denied, contact the Director of Recruitment at 646-565-5894.

Services for the UnderServed (S:US) believes every New Yorker has the right to lead a life of purpose. Since 1978, S:US has been turning this belief into reality by advocating for people with life circumstances marked by homelessness, intellectual/developmental disability, behavioral health and addiction challenges, poverty, criminal justice involvement, and trauma. Our dedicated workforce of 2,400 provides services and supports to transform the lives of 35,000 individuals and families in New York City and Long Island. Learn more about S:US, our mission, and values by visiting

Benefits Overview: We offer attractive compensation with comprehensive benefits including: Medical/Dental/Prescription/Vision/Life Insurance; 403(b); Credit Union; FSAs; Short-and-Long-Term Disability; Transportation Plan; Generous Paid Vacations and Holidays

External Company Name: Services For The Underserved, Inc.

External Company URL:

Street: Veterans Services Admin