BHCP Care Coordinator

University of Massachusetts Medical School • Westborough, MA

3d

About The Position

Under the general supervision of the Associate Director, or designee, the Behavioral Health Care Partner (BHCP) Care Coordinator manages an assigned caseload of nursing facility residents identified through the Preadmission Screening and Resident Review (PASRR). The coordinator ensures residents with confirmed serious mental illness (SMI) receive recommended PASRR services and supports and, for residents interested in community living, monitors progress toward that transition. The role focuses on care coordination, resident advocacy, service oversight, documentation, and collaboration with facilities, providers, state agencies, and other organizations. The position has a MetroWest Massachusetts focus area.

Requirements

• Bachelor’s degree in social work, a related health and human services field, or equivalent; alternatively, an LPN with an associate’s degree or equivalent.
• Two years of work experience providing direct service, care coordination, or case management to adults with psychiatric disabilities, including one year in a medical or clinical setting with knowledge of medical terminology.
• Demonstrated knowledge of and experience with relevant social service and rehabilitation systems.
• Ability to travel statewide and a valid driver’s license.
• Proficiency with Microsoft applications, including Word, Outlook, and databases.

Responsibilities

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

What This Job Offers

• Job Type: Full-time