Wellness Coordinator (Registered Nurse)

BHG Careers•Johnston, RI

4d•Hybrid

About The Position

The Wellness Coordinator will lead and manage the Health Home (HH) Team to ensure high-quality support and comprehensive care for patients. This role involves identifying OTP (Opioid Treatment Program) patients, conducting outreach, assessing needs, and developing individualized care plans in collaboration with patients. The Coordinator also collaborates with case managers, facilitates team meetings, and manages patient engagement strategies, covering all aspects of Health Home services such as care management, care coordination, health promotion, transitions of care, and community referrals. The role ensures compliance with all federal, state, and local regulations and accrediting agencies, and supports an inclusive work environment embracing diversity.

Requirements

Master’s degree in Social Services, Psychology, Social Work, or Criminology or Registered Nurse (RN) license.
Familiarity with behavioral health and related experience.
Strong integrity and excellent communication skills to engage with diverse backgrounds.
Structured approach to handling high caseloads.
Ability to work at other BHG Rhode Island locations as needed.
Visual acuity for reading and computer work.
Ability to sit for extended periods, with occasional bending and stretching.
Effective verbal communication skills for in-person and phone interactions.
Ability to perform keyboarding for extended periods.

Nice To Haves

New Master level graduates encouraged to apply.

Responsibilities

Facilitate Medicaid enrollment and automatic enrollment in the Health Home program, offering opt-out options.
Monitor and bill Health Home service notes using SAMMS.
Develop and implement a flexible, patient-centered care plan addressing clinical and non-clinical needs; update care plans based on any health changes.
Collaborate with Wellness nurses and providers on discharge planning for OTP patients and new referrals.
Coordinate access to preventive, health promotion, mental health, and substance use services.
Support continuity of care through comprehensive care management, care coordination, and transitional care.
Connect patients to community resources, social support, long-term care, and recovery services.
Educate and assist new patients in understanding and enrolling in the Health Home Program.
Offer practical support, advocacy, and problem-solving assistance to patients.
Provide nutritional education related to specific medical issues and conduct wellness interventions.
Maintain agreements with local hospitals and healthcare providers to support transitional care and enhance patient outreach.
Oversee a continuous quality improvement program, collecting data to evaluate and improve care coordination, outcomes, and service quality.
Ensure compliance with all federal, state, and local regulations and accrediting agencies.
Support and contribute to an inclusive work environment, embracing diversity.