RN, BH Transition of Care Coordinator

About the role

Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program. GLFHC is currently seeking a Registered Nurse, Behavioral Health Transition of Care Coordinator.

Responsibilities

• Supports high-risk patients by ensuring timely and effective transitions from inpatient, emergency department, and other levels of care back into the community.
• Focuses on individuals with behavioral health needs, with the goal of improving care continuity, reducing avoidable utilization (reducing total cost of care), supporting ACO quality outcomes and serves as liaison with hospitals, inpatient facilities, behavioral health and integrated care teams to support coordinated and timely transitions of care.
• Ensures compliance with MassHealth Transitions of Care contract requirements.
• Serves as a critical interface with the Behavioral health GLFHC team who is responsible for securing post discharge follow up appointments are in place.
• Identify and track patients discharged from inpatient facilities and emergency department.
• Conduct timely outreach within 24-72 hours post-discharge in alignment with TOC requirements.
• Ensure completion of 7-day follow-up visit after a behavioral health hospitalization or ED visit.
• Monitor and address missed or canceled appointments to support continuity of care.
• Implement strategies to improve appointment adherence and continuity of care.
• Develop, implement, and update, individualized care plans in collaboration with interdisciplinary care teams.
• Carefully coordinate services with C3 ACO BH TOC team for any Greater Lawrence patients discharge from facilities outside the service area.
• Carefully coordinate services across primary care, behavioral health providers, hospitals, and community organizations.
• Address barriers to care, including transportation, housing and other health related social needs.
• Support referral completion and ensure appropriate follow-up services are in place.
• Engage patients and caregivers in care planning with a focus on behavioral, social and patient-centered needs.
• Provide education on behavioral health conditions, discharge plans and symptom management strategies.
• Serve as a primary point of contact for behavioral health facilities, to support discharge planning and coordination.
• Complete TOC workflows, including medication review, discharge plan review, and risk assessment.

Qualifications

• Bachelor’s degree in Nursing.
• License in MA.
• 2-3+ years of experience in behavioral health, care coordination, case management or transitions of care.
• Experience working with patients with chronic and behavioral health conditions.
• Demonstrates ability to work effectively within multidisciplinary care teams.
• Ability to be flexible and utilize clinical expertise to solve complex problems.
• Bi-lingual Spanish speaking highly desirable.
• Valid driver’s license.

Benefits

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.