Behavioral Health Care Partner (BHCP) Care Coordinator

UMass Chan Medical School; Westborough (MA); On-site; USD 60,000 - 75,000; Full time

Job summary

UMass Chan Medical School seeks a Behavioral Health Care Partner Care Coordinator to manage PASRR-linked caseloads in nursing facilities. You will conduct regular resident visits, document clinical summaries, and ensure delivery of PASRR services while advocating for resident needs.

Travel statewide, coordinate with guardians and facilities, and participate in care planning meetings. Strong knowledge of social services and medical terminology is preferred; confidentiality and quality improvement

Qualifications

• Bachelor's degree in social work or related health/human services field, or equivalent.
• LPN with an Associate Degree (or equivalent) required?
• 2 years experience providing direct service, care coordination, or case management to adults with psychiatric disabilities, including at least 1 year in medical/clinical settings with medical terminology knowledge.
• Knowledge of social service/rehabilitation systems.
• Ability to travel statewide with valid driver’s license.
• Proficient with Microsoft Word, Outlook, and database applications.

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, with at least one in-person visit per quarter.
• Review and document all relevant information including written clinical summaries into data system applications.
• Participate in quarterly nursing care planning meetings with the nursing facility.
• Advocate for residents to ensure needs are met.
• Ensure PASRR services are delivered to residents.
• Identify service gaps and propose solutions through innovative programming.
• Monitor clinical appropriateness of facility and community-based supports; address issues accordingly.
• Escalate concerns to the proper oversight authorities.
• Maintain individual records of encounters in data systems.
• Prepare responses to statistics and data requests.
• Foster continuity of care and partnerships with health care providers and facilities.
• Participate in public relations, conferences, and meetings as needed.
• Maintain confidentiality per HIPAA and organizational policies.
• Engage in performance improvement and quality assurance initiatives.

Skills

Care coordination

Case management

Travel statewide

Microsoft Office

Microsoft Word

Microsoft Outlook

Database literacy

Education

Bachelor's degree in social work or related health/human services field

Licensed Practical Nurse (LPN) with an Associate Degree

Tools

Database software

Job description

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.

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

OR

• A Licensed Practical Nurse (LPN) with an Associates 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 drivers license
• Proficient in the use of Microsoft Applications, including Word, Outlook and database

The University of Massachusetts Chan Medical School welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.