Behavioral Health TOC RN - Hybrid

Greater Lawrence Family Health Center, Inc.; Methuen (MA); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Tuition reimbursement

Comprehensive benefits

Growth opportunities

Job summary

Greater Lawrence Family Health Center, Inc. is seeking a Registered Nurse, Behavioral Health Transition of Care Coordinator to support high-risk patients through timely transitions from inpatient, ED, and other care settings into the community.

The hybrid role involves remote opportunities with onsite meetings at local practice locations. The TOC Coordinator will engage patients with complex behavioral health needs, coordinate with interdisciplinary teams, and ensure follow-up and discharge

Qualifications

• RN licensed in MA.
• 2–3+ years in behavioral health, care coordination, case management or transitions of care.
• Experience with patients with chronic and behavioral health conditions.
• Ability to collaborate within multidisciplinary care teams.
• Bi-lingual Spanish speaking highly desirable.
• Valid driver's license.

Responsibilities

• Identify and track patients discharged from inpatient facilities and ED.
• Conduct timely outreach within 24-72 hours post-discharge in alignment with TOC requirements.
• Ensure completion of 7-day follow-up visit after a behavioral health hospitalization or ED visit.
• Monitor and address missed or canceled appointments to support continuity of care.
• Implement strategies to improve appointment adherence and continuity of care.
• Develop, implement, and update individualized care plans in collaboration with interdisciplinary care teams.
• Coordinate services with C3 ACO BH TOC team for Greater Lawrence patients discharge from facilities outside the service area.
• Coordinate services across primary care, behavioral health providers, hospitals, and community organizations.
• Address barriers to care, including transportation, housing and other health related social needs.
• Support referral completion and ensure appropriate follow-up services.
• Engage patients and caregivers in care planning with a focus on behavioral, social and patient-centered needs.
• Provide education on behavioral health conditions, discharge plans and symptom management strategies.
• Serve as a primary point of contact for behavioral health facilities, to support discharge planning and coordination.
• Complete TOC workflows, including medication review, discharge plan review, and risk assessment.

Skills

Behavioral health

Care coordination

Case management

Transitions of care

Multidisciplinary teamwork

Communication

Education

Bachelor's degree in Nursing

Job description

Greater Lawrence Family Health Center, Inc. is seeking a Registered Nurse, Behavioral Health Transition of Care Coordinator to support high-risk patients through timely transitions from inpatient, ED, and other care settings into the community.

The hybrid role involves remote opportunities with onsite meetings at local practice locations. The TOC Coordinator will engage patients with complex behavioral health needs, coordinate with interdisciplinary teams, and ensure follow-up and discharge