BHCP Care Coordinator

University of Massachusetts Medical School • Westborough, MA

1d

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 position ensures residents with confirmed serious mental illness (SMI) receive recommended PASRR services and supports and, for residents interested in community living, monitors progress toward transition.

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.
• At least one year of experience in a medical or clinical setting, including knowledge of medical terminology.
• Demonstrated knowledge of and experience with relevant social service and rehabilitation systems.
• Ability to travel statewide with a valid driver’s license.
• Proficiency with Microsoft applications, including Word and Outlook, and database applications.

Responsibilities

• Serve as care coordinator for an assigned caseload of nursing facility residents.
• Conduct monthly in-person or virtual visits with each resident and, if 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 according to program guidelines and regulations.
• Participate in quarterly nursing care planning meetings with nursing facilities.
• Advocate for assigned residents to ensure their needs are 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 as needed.
• 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 and participant encounters and contacts in data system applications according to program guidelines and regulations.
• Support the preparation of and responses to requests for statistics and resource or service data.
• Promote continuity of care and cooperative partnerships by liaising with healthcare providers, acute care hospitals, long-term care facilities, and other service organizations and programs.
• Participate in public relations efforts, including conferences and meetings as needed.
• Maintain positive working relationships with applicants and 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 applicable health, safety, and program regulations and requirements.

What This Job Offers

• Job Type: Full-time