Advanced Practice Registered Nurses / Physician Assistants
CCN Registered Nurse (RN)
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The CCN (Coordinated Care Network) RN will provide coordinated Behavioral Health (BH) care management services as an integrated member of the care management team to adult Enrollees in need of services. Responsible for reviewing Enrollee’s medical information, compliance with prescriptions and medications.
Work collaboratively and effectively with care management team, including Assigned or Engaged Enrollees, their family/caregiver(s), medical team, and other providers to coordinate BH care management services.
Complete Comprehensive Assessments for all Engaged Enrollees from the Accountable Care Organization (ACO)/Managed Care Organization (MCO). Facilitate approval of the Comprehensive Assessments within 90 days of Enrollee’s assignment.
Review and sign off on Comprehensive Assessments.
Conduct medication reconciliation for each Engaged Enrollee who is discharged from an inpatient stay within three (3) business days of the date of discharge.
Contact Engaged Enrollee’s Primary Care Physician (PCP) to verify that medication orders from discharge are appropriate, that medication orders are filled correctly. Check for discrepancies and issues of medication non-compliance particularly in cases of multiple prescribers.
Ensure the Engaged Enrollee demonstrates an understanding of medication administration and support adherence to their medication regime.
Identify supports that are available or could be made available to support the Engaged Enrollee in medication administration and for Enrollees participating in a Medication Assistance Program (MAP) share updated medication order forms from the Engaged Enrollee’s PCP or discharging hospital.
Utilize the Comprehensive Assessment, and work with Engaged Enrollee, family/caregiver(s) and providers to develop a Person Centered Treatment Plan (PCTP) within 90 days of Enrollee’s Assignment. Update the PCTP at least every 6 months.
Monitor adherence to PCTPs, evaluate effectiveness, monitor Enrollee progress, and facilitate changes as needed in a timely manner.
Create ongoing process for Enrollee and family/caregiver(s) to determine and request the level of care coordination to support their desire at any given time.
Ensure that the PCTP meets the requirements of EOHHS and notify the ACO/MCO if changes have occurred since the completion of the Comprehensive Assessment.
Ensure the Engaged Enrollee receives the necessary assistance and accommodations to prepare for, fully participate in and, to the extent preferred, direct the treatment planning process.
Facilitate Enrollee access to appropriate medical and specialty providers.
Ensure the Engaged Enrollee receives assistance in understanding BH terms and BH concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the treatment planning process; self-directed care options and assistance available to self-direct care; and BH services or programs that are available to meet their needs and for which they are potentially eligible.
Conduct an assessment of the Engaged Enrollee for social services and identify community and social services and resources that may support the health and well being of the Engaged Enrollee.
Conduct assessment for Flexible Services for all Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified, make recommendation to ACO for approval.
Provide BH subject matter expertise to health care, behavioral health, and social service providers.
Coordinate all aspects of service delivery and promote integration with healthcare providers, BH providers, and community/social services providers that the Engaged Enrollee may be receiving, as outlined in the PCTP.
Facilitate and attend meetings between Enrollee, family/caregiver(s), care team, payers, and community resources as needed.
Provide health and wellness coaching as directed by the Engaged Enrollee’s care team and as indicated in the Enrollee’s PCTP.
Maintain regular contact with Engaged Enrollee to monitor and coordinate PCTP including quarterly face-to-face meetings.
Complete all required documentation in a timely manner.
Provide outreach and engagement services to individuals as needed including transportation for services related to their PCTP.
Provide transition planning and transition coordination to Engaged Enrollee including follow-up support post discharge.
Work in collaboration with CCN’s lead agency in all aspects of delivering BH Community Partner services.
Utilize a person-centered approach when planning and delivering services in partnership with all enrollees, associated support systems such as family members, friends, guardians, and all medical and behavioral health providers.
Anticipate issues of medical risk and attend to crisis or emergency situations by intervening immediately with appropriate clinical/medical treatment and/or supervision. Develop medical protocols for individuals as needed.
Provide in-service trainings regarding medication administration and medical supports for CCN staff as needed.
Execute duties to reflect reasonable safety standards. Standard precautions must be utilized and training obtained in areas that constitute risk.
Perform duties to reflect agency/program/CCN policies and procedures.
Perform other related work duties as needed or as assigned by supervisor.
Registered Nurse in Massachusetts plus 2 years of experience working with individuals with mental health and/or substance use.
Competency with medical and psychiatric monitoring.
Knowledge of the theories, methods, procedures and practices of nursing care and physical rehabilitation as applicable to community services.
Experience navigating individual and family service systems and demonstrated capacity to work collaboratively and effectively with families and community-based colleagues.
Ability to use Care Management Software and document and coordinate services.
Must be able to perform each essential duty satisfactorily.
Strong interpersonal skills in terms of developing a working relationship with a variety of individuals in a variety of contexts. Ability to communicate effectively verbally and in writing.
Strong organizational skills with attention to detail, multi-tasking skills, prioritization skills, analytical skills, problem-solving skills and team skills.
Demonstrated ability to function independently at a high level of competence.
Ability to travel on a regular basis. Must possess a valid driver’s license in state of residence, and have own means of transportation.
Strongly prefer that a candidate will have a demonstrated understanding of and competence in serving culturally diverse populations.
Ability to read and speak English. Fluency in other languages especially Spanish, Portuguese, Cape Verdean Creole, and/or Haitian Creole preferred.
BAMSI is a 1900+ employee health and human services organization with locations across eastern Massachusetts. We offer generous paid time off (6 weeks combined Vacation, Sick and Personal time off paid), paid holidays, and paid trainings in a supportive environment that offers growth opportunities! Health, Dental, Short Term, Long Term and Vision Insurance are also available.
BAMSI is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.
Internal Number: 38570
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The American Psychiatric Nurses Association is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.