Nursing Supervisor - Care Coordination

Countywide, MA

General Description

Supervise Nurse Care Manager(s) and program nurses regarding wellness, nursing needs, and other initiatives in the Behavioral Health Community Partner (BHCP) program.  Oversee nursing, quality Improvement (QI), and Transition of Care (TOC), in conjunction with program director.

Supervises Transition of Care Coordinator and Co supervises the Program Nurse. In conjunction with the Program Director, management and oversight of all nursing and medical needs, wellness, Quality Improvement (QI), and other initiatives in the Behavioral Health Community Partner (BHCP) program. 

Essential Job Functions:

Responsibilities:

Nursing

  • Working closely with the Program Director, Care Managers, and Care Coordinators, maintain management and oversight of all medical / nursing program needs, responsibilities, and standards.
  • Collaboration and Coordination with all BHCP team members to ensure integrated care management for our enrollees.  
  • Meet with Director, Program Director, Director of Nursing and Medical Director to ensure quality medical service.
  • Collaborate with internal and external disciplines including but not limited to psychiatrists, primary care physicians, nurses, and clinicians to provide integrated care management through oversight and direct case management activities.
  • Work with community-based organizations including, but not limited to, the ACO and PCP to deliver services to the BHCP enrollees.
  • Meet with members to discuss Wellness goals, complete assessments and care plans as needed.
  • Manage, facilitate and/or oversee wellness groups within BHCP program.  
  • Oversee and track medication reconciliation, review nursing client lists and work closely with staff to ensure integrated transitions of care.
  •  Audit Client Care Plans on a quarterly basis to ensure all care needs are being met.
  • Maintain and manage the needed inventory of medical supplies for BHCP Program
  • Interview nursing applicants, make hiring recommendations, and facilitate training of new nurses.
  • Support Director and Program Director.

  

Quality Improvement/Quality Management

  • Facilitate monthly BHCP QI Committee meetings.
  • Attend quarterly organizational QI Committee meetings.
  • Develop QI projects and track results monthly.
  • Coordinate QI functions; assist staff with planning, implementation of Plan Do Study Act (PDSA) cycles and data reporting as needed.
  • Work with BHCP Director and Program Director to define, develop and document consistent data standards and definitions for reporting and analysis purposes.
  • Complete quarterly client record audits and generate reports to identify trends and to make practice specific recommendations.
  • Support the analysis and reporting of periodic performance data.
  • Gather data from ACO/MCO’s to assist with model analysis, costs and outcomes.
  • Utilize data and other tools to assess and report on performance related to BHCP contract requirements, including program efficiency and EOHHS quality measures.

Transition of Care

  • Engage Brien Center BH CP Assigned and Engaged Enrollees in the inpatient, ED and crisis settings to deliver BH CP services immediately review and prioritize a list of hospitalized BH CP Assigned and Engaged Enrollees on a daily basis; meet with Enrollees immediately upon identification of all individuals who are utilizing facility-based services.
  • Delegate support functions to additional BH CP staff (e.g. Care Coordinators), to meet with 100% of Enrollees who utilize facility-based services on a daily basis. Follow-up with Enrollees who are not available at an initial contact on the same day of such contact.  Track and follow-up with Enrollees who have left the facility on the day of discharge either directly, or in combination with BH CP team members.
  • Complete all required documentation in a timely manner
  • Consult with Brien Center BH CP medical, behavioral and other staff, as needed, to meet the person-centered needs of Brien Center BH CP Enrollees.
  • Convene Interdisciplinary Care Team (ICT) meetings, as needed, for the purpose of planning TOCs. Collaborate with BH CP staff to plan and execute such meetings and transitions.
  • Collaborate with Berkshire Health System care management and discharge planning staff, providers, community-based Social Service Providers, BH CP team members, Crisis Teams, and other community-based supports to ensure the delivery of whole-person BH CP care management services including, but not limited to, effective transitions of care for Enrollees who utilize inpatient, ED, crisis and other facility-based health care services
  • Attend and actively participate in TOC and discharge planning meetings and the development of interventions at the earliest point in the Enrollee’s facility -based care
  • Establish positive relationships with community organizations and services for the purpose of initiating and implementing meaningful TOCs.
  • Collaborate with Brien Center BH CP staff to review and augment Assessments and PCTPs to include appropriate information and goals for individuals who experience facility-based TOCs.
  • Provide temporary assistance with transportation to needed TOC-related appointments in the absence of Care Coordinator or other options.
  • Manage Care Coordinator follow-up of all TOC interventions in collaboration with BH CP staff.
  • Meet reporting requirements to inform the ACO of TOC activities.

Qualifications:

  • Registered Nurse with current licensure in Massachusetts required.
  • Minimum of five years experience in nursing or healthcare within the last five years (IN TOC).
  • Five years experience working with adults with serious and persistent mental illness and substance use disorders.
  • Five years experience with local resources, navigating health, behavioral health, and substance use treatment systems.
  • Minimum of 2 years experience in a supervisory position required.
  • Experience in performing oversight activities, quality assurance, and compliance training.
  • A track record of producing work that is highly accurate and demonstrates attention to detail.

 Other Requirements:

  • Participate in supervision as required
  • Participate in all trainings as required
  • Represent agency in a professional manner in all community contacts.
  • Maintain programmatic policy and procedure manuals based on current regulations and standards.
  • Maintain ethical and professional standards.
  • Demonstrate a commitment to the Agency’s mission and community mental health principles.
  • Driver’s license checks (RMV).
  • Criminal Offender Record Information Check (CORI).
  • Knowledge of EHR systems
  • Meet all credentialing requirements

Skills:

  • Excellent written and verbal communication skills.
  • The ability to pay close attention to detail.
  • Flexible and able to adapt to frequently changing standards and priorities.
  • Proficiency with computer and EHR systems
  • Excellent communication, documentation, time management, and organizational skills.
  • Excellent collaboration and relationship building skills 

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