Nurse Care Manager- One Care Worcester

Behavioral Health Network (BHN) is a leading statewide provider of behavioral health services and a Certified Great Place to Work. Since 1938, BHN has helped individuals, families, and communities thrive through compassionate, high-quality care and support. We are currently seeking a Nurse Care Manager to join our One Care team and help advance our mission of empowering people to live healthier, more fulfilling lives.

• Purpose-Driven Work
  - Make a meaningful impact in the lives of individuals, families, and communities throughout Western Massachusetts.
• Professional Growth
  - Access ongoing training, mentorship, career development, and advancement opportunities across one of the region's largest behavioral health organizations.
• Supportive Team Culture
  - Join a collaborative workplace guided by our HEART values:
  Humanity, Empowerment, Accountability, Respect, and Teamwork.
• Stability & Opportunity
  - Build your career with a well-established organization serving Western Massachusetts since 1938.
• Comprehensive Benefits
  - Generous PTO, 403(b), educational assistance, medical, dental, vision, employee assistance programs, and more.
• Certified Great Place to Work
  - Work for an organization recognized for creating a positive and engaging employee experience.

Act as a strong advocate for individuals served, ensuring their voices are heard and their needs are met, and empower them to make informed decisions about their care while promoting autonomy and self-determination. Include all appropriate parties in the individual's Integrated Care Team, including primary care providers, behavioral health providers, and others as indicated by the individual served. Build and maintain strong relationships with community partners, including social service agencies, healthcare and behavioral health providers, and other relevant organizations.

Complete and maintain accurate and timely documentation of individual served interactions, progress, and referrals, and complete necessary reports for funding agencies and other stakeholders. Work to reduce individuals served utilization of higher levels of care when appropriate and support transitions from inpatient settings (e.g., emergency room, inpatient hospitalization, detox) back into the community. Review initial and annual MDS assessments in collaboration with the care team to identify health needs, safety concerns, and gaps in care.

Provide care management services including post-hospitalization follow-up and medication reconciliation. Provide ongoing care management for an assigned caseload, collaborating with the care team to identify risks or gaps in individuals' physical or mental health care. Promote the use of InstED emergency department services with individuals served and the care team. Perform a minimum of one monthly face-to-face outreach visit from the assigned caseload, understanding frequency may change according to individual and program needs.

Evaluate individuals served medical history and diagnoses for accuracy; assess health needs, health history, and existing support network. Assist the care team in creating a person-centered care plan and scheduling appointments as needed. Educate individuals served and their families/supports on relevant health-related matters. Monitor individuals served outcomes and collaborate with medical and/or behavioral health providers to ensure continuity of care, providing recommendations for treatment changes as appropriate.

Maintain familiarity with One Care policies and procedures and adhere to updates or changes. Provide ongoing information, periodic reviews, and documentation to support care plan goals and objectives. Work with individuals served, providers, and care team to help close gaps in care and advocate for best health and wellness outcomes. Consult with community agencies, providers, and informal supports to maintain coordination in the treatment process..

Consult with the care team on cases as needed regarding medical and/or behavioral health issues. Provide consultation and assist with completion of the Critical Incident Reporting process as needed. Provide formal and informal training to the care team regarding health/medical issues facing individuals served.

High School Diploma or GED required. Registered Nurse license required. 1-2 years' work experience in related behavioral health, human services, and/or medical field required. Demonstrates cultural and linguistic competence in working with…