Job Description

Job Location 415 Columbia Rd - Dorchester, MA 02125 Position Type Full Time 30+ hours Education Level 2 Year Degree Travel Percentage Negligible Job Shift Day Job Category Health Care

Position Title: Behavioral Health Community Partnership (BHCP) Nurse Case Manager
Department: Social Services
Supervisor: Director of Nursing
Status/Hours Per Week: Non-exempt / 35 hours

Pay Range: The expected base pay for the position is $36-$65.02 per hour and may be increased based on other factors, such as language, certifications, etc.

Primary Function:

The Behavioral Health Community Partnership Nurse Case Manager [BHCP RN Case Manager] functions under the supervision of the Director of Nursing and overall guidance and consultation with the Medical Director and other Primary Care Providers to conduct patient monitoring, tracking, and provide ongoing care coordination and support to patients with behavioral health issues that are enrolled in BHCP. The BHCP RN Case Manager ensures patients’ adequate linkages with behavioral health counseling, all levels of substance use care, including medication assisted treatment, and chronic pain management care.

Duties & Responsibilities:

• Receive and maintain a log of all patients enrolled in BHCP, and ensure adequate follow up and care coordination.

• Serve as Clinical Care Manager for enrollees referred to the team, participating in the assessment, care planning, and on-going BHCP service provision specified in program protocols and policies.

• Review and approve Comprehensive Health Assessments for members including performing medication reconciliations.

• Make patient referrals to behavioral health, and human services providers at the Health Center for needed services such as primary care and other substance use and mental health care.

• Make “warm handoffs” and coordinate support to needed services at external organizations including hospitals, substance use treatment programs, etc.

• Follow up with members post-discharge to ensure members are seen by a Primary Care provider in a timely manner.

• Monitor and track patients including progress in their treatment plan and update PCPs and other members of the team.

• Participate in multi-disciplinary team meetings, utilization review, and program planning.

• Participate in consultation, sharing of resources and best practices with other Riverside Community Partner teams.

Qualifications

Minimum Basic Knowledge:

• Good knowledge of common computer programs and use with an EHR or willingness to learn.

• Experience or a desire to work in a community setting and with low income populations; sensitivity to socio-economic, trauma, and other factors impacting various communities.

• Familiarity with UCC neighborhoods and agencies is an added plus.

• Exhibit an aptitude for thinking creatively in the engagement and support of individuals as they navigate through the challenges of behavioral health, substance use and recovery.

Experience &

Qualifications:

• Licensed as Registered Nurse in Massachusetts.

• Two years of nursing experience, preferably in an ambulatory care or community health setting preferred.

• Experience with Behavioral Health and/or Substance Use Disorders and chronic pain management is a plus.

• Experience with case management and care coordination.

• Experience with EMR and related care management registries, databases and Information Technology/Computer Systems.

• Excellent communication and clinical judgment skills.

• Ability to follow and adhere to care model’s operating procedures and standards.

• Bilingual language skills in English/Spanish, Portuguese or Vietnamese desirable.

• Competency/experience in diverse settings and working on a multi-disciplinary team.

• Commitment to community/public health.

• Ability to complete mandatory trainings on-site via online learning system (Health Stream, etc.), and others deemed necessary for case management.

• Maintain awareness and experience with topics/subject areas of Harm Reduction, Aging Population, Addiction/Behavioral Health, and Social Determinants of Health and Health Disparities within communities and special populations.

Essential Functions:

• Case management and care coordination of services for patients following BHCP protocols.

• Effective and efficient delivery of services to various patient groups, with sensitivity to socio-economic, trauma, and other factors impacting communities with high-needs.

• Effective communication and sharing of information with patients, providers and external partners.

• Collaborative approach to working with BHCP team, internal and external providers.

• Complete and accurate documentation of care coordination activities and treatment progress of assigned patients.

Physical Requirements:

• Capacity to transport patients or things from place to place while bearing the weight 0-30 pounds.

• Capacity to raise objects from lower to higher position, from higher to lower position and horizontally 0-30 pounds.

• Capacity to sit for prolonged periods of time during meetings and desk work.

Supervisory Responsibility:

None

Define Access Level to PHI: Level 4: Authorized to access full health information. UCHC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.