BHCP Care Coordinator

UMass Med School; Westborough (MA); On-site; USD 60,000 - 70,000; Full time

Job summary

UMass Chan Medical School seeks a Behavioral Health Care Partner Care Coordinator to manage PASRR-based caseloads in nursing facilities across the MetroWest MA focus area. You will conduct regular visits, document carefully, and coordinate PASRR services to support residents toward community living.

The role requires collaboration with guardians, facility staff, and state agencies, plus travel across the state as needed. A relevant degree or LPN license with clinical experience is required.

Qualifications

• Bachelor's degree in social work or related health and human services field is required.
• LPN with an Associate's Degree or equivalent is required.
• 2 years of direct service, care coordination, or case management experience with adults with psychiatric disabilities, including 1 year in medical/clinical setting.
• Experience with social service/rehabilitation systems and ability to travel statewide with a valid driver's license.
• Proficient in Microsoft Office applications (Word, Outlook, databases).

Responsibilities

• Serve as a care coordinator for an assigned caseload of nursing facility residents.
• Conduct monthly visits with residents and guardians, with at least one in-person visit per quarter.
• Document information in data systems per guidelines.
• Participate in quarterly nursing care planning meetings.
• Advocate for residents to ensure needs are met.
• Ensure PASRR services are delivered to residents.
• Identify gaps and propose innovative program solutions.
• Monitor clinical appropriateness of facility and community supports.
• Escalate concerns to oversight authorities.
• Assist in transition planning to community living when applicable.
• Maintain records of encounters in data systems.
• Assist in preparing statistics and resource data requests.
• Foster partnerships with healthcare providers and facilities.
• Participate in public relations and conferences as needed.
• Maintain relationships with participants and providers; protect confidentiality per HIPAA.
• Support performance improvement and quality initiatives.
• Comply with department policies and safety regulations.

Skills

Care coordination

Medical terminology

Microsoft Office

Education

Bachelor's degree in social work or related field

Licensed Practical Nurse (LPN) with an Associate's Degree

Tools

Microsoft Word

Outlook

Database systems

Job description

US-MA-Westborough

Exempt

Full-Time

USD $60,000.00/Yr.

USD $70,000.00/Yr.

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

Additional Information

METROWEST MA FOCUS AREA