Assessment Nurse Care Coordinator - Per Diem

Since 1985, BHCHP’s mission has been to provide or assure access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. We care for over 11,000 homeless individuals each year and ensure that every one of these individuals can receive comprehensive health care, which includes primary care, behavioral health, medical respite, dental, case management, and more.

Our staff work in 30+ locations across the city to serve some of our community's most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity, centering trust, mutual respect, hope, and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down physical and systemic barriers that our patients face and provide community-based health care services that are compassionate, dignified, and culturally appropriate.

Hours:

Per Diem – as needed, during the hours of 8:30am-5:00pm Monday – Friday Union:
No Union Name:
Non-union Patient Facing:
Yes

BHCHP is seeking an RN who is interested in flexible weekday hours and working on a small, tight-knit team that provides care coordination services to clients enrolled in the BHCHP One Care Program. The One Care program is a state initiative to promote care coordination, continuity of care, and improved health outcomes for those clients under 65 who are eligible for both Medicare and Medicaid.

In this role, you will mostly focus on performing Uniform Core Assessment (UCA) assessments and creating care plans customized to meet the needs of individual clients. UCA training is provided by Commonwealth Care Alliance (CCA)/Care Source. You will also help update these plans both annually and when a client has had a significant change in status. You will be required to provide face-to-face outreach to meet with clients, assess their status, and support the client’s progress toward better health outcomes.

You will also connect with clients by phone, communicate with providers about client needs, and connect clients to eligible services including visiting nursing, nutrition, durable medical equipment, and social services.

Clients may be housed; living in shelters or on the streets and you will need to be resourceful to connect with our clients. It is anticipated that success with connecting with clients will require communication with BHCHP care teams and shelter partners, use of BHCHP and CCA/Care Source electronic medical records, as well as outreach to clients who are living on the street, shelter, or in temporary or permanent housing.

You will need to remain flexible and creative, as this role will continue to evolve as experience is gained. There is potential for this role to expand to full-time hours in the future if the candidate is interested.

• Assumes responsibility for the coordination of care between BHCHP medical teams and the One Care program for BHCHP clients who are enrolled in the One Care Program.
• Conducts UCA assessments for clients enrolled in the One Care program; collaboratively participates as a member of the primary care team that includes M.D.s, N.P. /P.A. s, Clinical RNs, behavioral Health Clinicians, Medical Assistants, Case Managers and others.
• Communicates with clients and/or caregivers including performing outreach as necessary in the greater Boston area for face-to- face contact to homes, hospitals, other facilities, etc. as needed to assess build relationships, client status, and identify new care needs; communicates clearly and…