Overview Under the general supervision of the Associate Director, or designee, the Behavioral Health Care Partner (BHCP) Care Coordinator is responsible for completing and managing a caseload of nursing facility residents who have been identified through the Preadmission Screening and Resident Review (PASRR). This position ensures that nursing facility residents with confirmed serious mental illness (SMI) receive all recommended PASRR services and supports, and for those residents who are interested, monitoring the progress towards community living. Responsibilities Serve as a care coordinator for an assigned caseload of nursing facility residents. Conduct monthly in-person or virtual visits with each nursing facility resident and guardians, if applicable with at least one in-person visit per quarter Review and document all relevant information including written clinical summaries into data system applications in accordance with program guidelines and regulations. Participate in quarterly nursing care planning meetings with the nursing facility. Act as an advocate for assigned nursing facility residents to ensure their needs are being met. Ensure all recommended PASRR services are delivered to assigned nursing facility residents. Identify service gaps and solutions to gaps through innovative programming Monitor the clinical appropriateness of the residents' facility and community-based supports and address issues accordingly Escalate concerns with the residents' care to the proper oversight authority(s) Act as an active member of the residents' transition planning to community living; if applicable Maintain individual records documenting all applicant/participant encounters and contacts into data system applications in accordance with program guidelines and regulations. Support in the preparation and responses to requests for statistics and resource/service data Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals, long term care facilities and other programs/organizations involved in the provision of services Participate in public relations efforts, attending conferences and meetings as needed Maintain positive working relationships with applicant/participants, and relevant informal supports, provider organizations, program consultants and state agencies Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations Participate in performance improvement initiatives and demonstrate the use of quality improvement in daily operations Comply with established departmental policies, procedures and objectives Comply with all health, safety and program regulations and requirements Qualifications Bachelors Degree in social work; a related health and human services field or equivalent. OR A Licensed Practical Nurse (LPN) with an Associate's Degree or equivalent. AND 2 years of work experience providing direct service, care coordination, or case management to adults with psychiatric disabilities, inclusive of 1 year of experience in a medical or clinical setting with knowledge of medical terminology. Demonstrated knowledge and experience with relevant social service/rehabilitation systems. Ability to travel statewide with a valid driver's license Proficient in the use of Microsoft Applications, including Word, Outlook and database