Nurse Care Coordinator

Sweetser; Sanford (ME); On-site; USD 94,558,000 - 103,155,000; Full time

Benefits offered by this job

Sign-on Bonus

Job summary

Sweetser in Sanford, Maine, is seeking a Nurse Care Coordinator to provide regional primary care and psychiatric care consultation and to collaborate with the Behavioral Health Home Organization and related teams. The role supports care across the healthcare continuum and offers a $5,000 sign-on bonus with a pay rate of $33–$36 per hour depending on experience.

The position requires RN licensure in Maine and a nursing degree, with duties including education, coordination, and discharge planning

Qualifications

• Experience coordinating care across behavioral health and primary care.
• Ability to educate patients and families about medications and chronic disease management.
• Proficient in EHR, HIN and VMS systems for clinical data access.
• Strong communication and collaboration with interdisciplinary teams.

Responsibilities

• Educate IDT, members, and families about medications.
• Educate on chronic disease management to IDT and groups.
• Liaise with Health Home, ACT Teams, CCBHC and PCPs.
• Collaborate with IDT on member care plans.
• Review health questionnaires and provide care recommendations.
• Assist with activities of daily living and health maintenance.
• Support grant-funded health initiatives in the service area.
• Support BHHO, CCBHC and Child ACT to meet organizational outcomes.
• Proficient in EHR, HIN, and VMS for data extraction.
• Consult on discharge planning and follow-up.
• Monitor ER usage and coordinate with providers.
• Medication reconciliation from external providers.
• Provide medication and medical education.
• Complete pharmacy enrollments and medical equipment orders.
• Provide CRMA training and supervision as needed.
• Schedules vary; on-call as assigned.

Skills

Care coordination

Interdisciplinary teamwork

Patient and family education

Clinical documentation

Education

Graduate from an accredited school of nursing

Current RN license in Maine

Job description

Becoming part of the Sweetser family means you can make a difference in the lives of Maine children, adults, and families every day. As a nationally recognized and accredited leader, we offer competitive salaries, a wide range of benefits and the opportunity to join a passionate team of more than 700 employees.

Nurse Care Coordinator

Job Code: 13380

Location: Sanford 04073

Department: Behavioral Health Home

FT/PT Status: Full Time

Summary

The Nurse Care Coordinator shall provide regional primary care consultation, psychiatric care consultation; work with the Behavioral Health Home Organization (BHHO) & Certified Community Behavioral Health Clinic (CCBHC) team, Child Assertive Community Treatment Team, Private Non-Medical Institute, and other members to facilitate care across the healthcare continuum.

$5,000 sign on Bonus! Rate: $33 - $36 depending on experience

ESSENTIAL FUNCTIONS

• Provide education and support around medications to the Interdisciplinary Team (IDT), members, and families.
• Provide medical education about chronic disease management to IDT members, families and groups.
• Liaison to Health Home, ACT Teams, CCBHC Practices/Primary Care Physicians.
• Collaborate with the IDT on member plan of care.
• Review Health Questionnaire and provide recommendations to IDT and/or members and families for medically compromised participants.
• Assist, and/or make recommendations regarding skill development in activities of daily living, including hygiene, nutrition, exercise, general health maintenance/improvement.
• Support implementation of grant funded projects such as In‑Shape, CTI, and other health and wellness pay for performance initiatives in geographical area where program is offered.
• Support Behavioral Health Home team, CCBHC and Child ACT in achieving organizational and state required outcomes, including but not limited to A1C testing, tobacco screening and annual health screenings .
• Be proficient in EHR, HIN, and VMS systems in order to extract clinical data and alerts in order to support level of care.
• Consult with IDT and members as indicated regarding discharge planning recommendations and follow up.
• Monitor emergency department usage and coordinate with IDT and other providers to promote least restrictive level of care.
• Medication reconciliation through EHR from external providers (i.e. PCP, Specialists, etc.) when appropriate.
• Provide medication and medical education to Interdisciplinary Team (IDT), members, and families.
• Complete pharmacy enrollments, medical equipment orders, and other supports/services to support recovery goals.
• Provide CRMA Training and Supervision as needed.
• Schedules will vary according to program needs (as applicable):
• On‑call responsibilities as assigned

GENERAL EXPECTATIONS

• Provide excellent customer service
• Active participation in supervision of student interns, as appropriate and needed.
• Ensure the confidentiality of all patient information and release of information from area(s) of responsibility.
• Ability to support and recognize the important role volunteers play. Sweetser employees work with, support, collaborate with volunteers, and promote opportunities for volunteer engagement
• Exercise judgment consistent with clinically accepted standards of community practice in determining whether to transport a particular patient(s).
• Maintain adequate personal vehicle insurance coverage, a valid state driver’s license, a vehicle that is in good repair and a good driving record as per organization policy.
• Active participation in required supervision as determined with Program Manager according to licensure level.
• Timely and accurate provision of administrative paperwork according to the time frame established by the organization’s policies.
• Active participation in administrative meetings, including program meetings and general staff meetings.
• Understand and comply with all Sweetser policies and procedures as identified in the Human Resources Policy Manual.
• Maintain administrative responsibility (charting/documentation, etc.)
• Active participation in in‑service training and continuing education programs.
• Active participation in providing community education to staff, community groups, etc., as appropriate and needed.
• Maintain minimum number of training hours mandated by professional licensure and required by state licensing.
• Maintain relationships with patients that promote dignity, equality and self‑determination.
• Provide productive and supportive collaboration with peers/colleagues in the same program and across programs.
• Maintain productive and efficient relationships with all organization‑wide personnel and programs.
• Maintain positive representation of the organization, at all times, with the public.
• Follow Suicide safer care practices.
• Other duties as assigned

EDUCATION

• Graduate from an accredited school of nursing.

CERTIFICATES, LICENSES, REGISTRATIONS

• Current RN license in the State of Maine.
• Maintain a valid state driver’s license.
• Must be able to speak, read, and write English fluently.

EXPERIENCE

• Previous experience working with adults with serious and persistent mental illness preferred.