Behavioral Health Care Partner (BHCP) Care Coordinator

University of Massachusetts Medical School; Westborough (MA); On-site; USD 55,000 - 85,000; Full time

Job summary

University of Massachusetts Medical School is seeking a Behavioral Health Care Partner Care Coordinator to manage PASRR-based services for nursing facility residents with SMI. You will perform monthly visits, document clinical information, and advocate for resident needs while coordinating with hospitals, facilities, and community programs.

Responsibilities include data entry, care planning participation, and identifying service gaps.

Qualifications

• Bachelor's degree in social work or related health and human services field.
• 2 years of direct service, care coordination, or case management with adults with psychiatric disabilities, including 1 year in medical/clinical setting.
• Ability to travel statewide with a valid driver's license.
• Proficient in Microsoft Word, Outlook and database usage.

Responsibilities

• Serve as a care coordinator for an assigned caseload of nursing facility residents.
• Conduct monthly in-person or virtual visits with each resident and guardians, with at least one in-person visit per quarter.
• Review and document all relevant information, including clinical summaries, into data systems per guidelines.
• Participate in quarterly nursing care planning meetings with the nursing facility.
• Advocate for residents to ensure their needs are met and PASRR services are delivered.
• Identify service gaps and develop innovative programming to address them.
• Monitor clinical appropriateness of facility and community supports and address issues.

Skills

Microsoft Office

Education

Bachelor's in Social Work

LPN with Associate's Degree

Tools

Word

Outlook

Database

Job description

Overview

Under the general supervision of the Associate Director, or designee, the Behavioral Health Care Partner (BHCP) Care Coordinator is responsible for completing and managing a caseload of nursing facility residents who have been identified through the Preadmission Screening and Resident Review (PASRR). This position ensures that nursing facility residents with confirmed serious mental illness (SMI) receive all recommended PASRR services and supports, and for those residents who are interested, monitoring the progress towards community living.

Responsibilities

• Serve as a care coordinator for an assigned caseload of nursing facility residents.
• Conduct monthly in-person or virtual visits with each nursing facility resident and guardians, if applicable with at least one in-person visit per quarter
• Review and document all relevant information including written clinical summaries into data system applications in accordance with program guidelines and regulations.
• Participate in quarterly nursing care planning meetings with the nursing facility.
• Act as an advocate for assigned nursing facility residents to ensure their needs are being met.
• Ensure all recommended PASRR services are delivered to assigned nursing facility residents.
• Identify service gaps and solutions to gaps through innovative programming
• Monitor the clinical appropriateness of the residents’ facility and community-based supports and address issues accordingly
• Escalate concerns with the residents’ care to the proper oversight authority(s)
• Act as an active member of the residents’ transition planning to community living; if applicable
• Maintain individual records documenting all applicant/participant encounters and contacts into data system applications in accordance with program guidelines and regulations.
• Support in the preparation and responses to requests for statistics and resource/service data
• Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals, long term care facilities and other programs/organizations involved in the provision of services
• Participate in public relations efforts, attending conferences and meetings as needed
• Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, program consultants and state agencies
• Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations
• Participate in performance improvement initiatives and demonstrate the use of quality improvement in daily operations
• Comply with established departmental policies, procedures and objectives
• Comply with all health, safety and program regulations and requirements

Qualifications

• Bachelors Degree in social work; a related health and human services field or equivalent.

OR

• A Licensed Practical Nurse (LPN) with an Associate’s Degree or equivalent.

AND

• 2 years of work experience providing direct service, care coordination, or case management to adults with psychiatric disabilities, inclusive of 1 year of experience in a medical or clinical setting with knowledge of medical terminology.

• Demonstrated knowledge and experience with relevant social service/rehabilitation systems.
• Ability to travel statewide with a valid driver’s license
• Proficient in the use of Microsoft Applications, including Word, Outlook and database