RN, BH Transition of Care Coordinator

Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.

GLFHC is currently seeking a Registered Nurse, Behavioral Health Transition of Care Coordinator to join our team. The Behavioral Health (BH) Transition of Care (TOC) Coordinator, RN supports high-risk patients by ensuring timely and effective transitions from inpatient, emergency department, and other levels of care back into the community. This important nursing role focuses on individuals with behavioral health needs, with the goal of improving care continuity, reducing avoidable utilization (reducing total cost of care), supporting ACO quality outcomes and serves as liaison with hospitals, inpatient facilities, behavioral health and integrated care teams to support coordinated and timely transitions of care. The responsibilities of this role align with the TOC follow-up as formally provided through the MassHealth Community Partner Program, including ensuring compliance with MassHealth Transitions of Care contract requirements. In addition, this role serves as a critical interface with the Behavioral health GLFHC team who is responsible for securing post discharge follow up appointments are in place.

This position plays a key role in engaging patients with complex behavioral health needs, many of whom face social and systemic barriers to care. The Behavioral Health Transition of Care Coordinator, RN provides outreach, care coordination and education tailored to each patient’s needs, meeting patients where they are, whether by phone, in the community, or clinical settings. This role is a hybrid model with remote opportunities and onsite presence at local practice locations for team meetings is expected.

• Identify and track patients discharged from inpatient facilities and emergency department.
• Conduct timely outreach within 24-72 hours post- discharge in alignment with TOC requirements.
• Ensure completion of 7-day follow-up visit after a behavioral health hospitalization or ED visit.
• Monitor and address missed or canceled appointments to support continuity of care.
• Implement strategies to improve appointment adherence and continuity of care.
• Develop, implement, and update, individualized care plans in collaboration with interdisciplinary care teams.
• Coordinates services with C3 ACO BH TOC team for any Greater Lawrence patients discharge from facilities outside the service area.
• Coordinate services across primary care, behavioral health providers, hospitals, and community organizations.
• Address barriers to care, including transportation, housing and other health related social needs.
• Support referral completion and ensure appropriate follow-up services are in place.
• Engage patients and caregivers in care planning with a focus on behavioral, social and patient-centered needs.
• Provide education on behavioral health conditions, discharge plans and symptom management strategies.
• Serve as a primary point of contact for behavioral health facilities, to support discharge planning and coordination.
• Complete TOC workflows, including medication review, discharge plan review, and risk assessment.

Qualifications

• Bachelor’s degree in Nursing. License in MA.
• 2-3+ years of experience in behavioral health, care coordination, case management or transitions of care.
• Experience working with patients with chronic and behavioral health conditions.
• Demonstrates ability to work effectively within multidisciplinary care teams.
• Ability to be flexible and utilize clinical expertise to solve complex problems.
• Bi-lingual Spanish speaking highly desirable.
• Valid driver’s license.

GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.