BH Care Coordinator

The Nurse Care Coordinator is responsible for coordinating comprehensive care transitions, hospital follow-up, disease management activities, and population health interventions for patients across emergency, inpatient, and ambulatory settings. This role ensures timely post-discharge contact, medication reconciliation, documentation in electronic systems, tracking of high utilizers and focused intervention groups, and support for metabolic screening and disease management programs. The RN collaborates with providers, Care Managers (NCM), behavioral health teams, and external partners to improve continuity of care, reduce readmissions, and meet quality and regulatory requirements.

Key Responsibilities:

• Conduct timely post-hospital and ER outreach, including medication reconciliation, virtual visits, and documentation.


• Manage care coordination workflows, including telephone encounters, record requests, and system updates.


• Track and support high utilizers and focused intervention groups.


• Participate in care team meetings, monitor follow-up appointments, and report relevant issues.

• Complete and distribute admit/discharge documentation and related system updates.


• Coordinate communication of admission and discharge information to relevant providers and care team members.


• Maintain accurate records of discharges in care management systems.

• Manage disease management screening processes, reporting, and scheduling for the DM population.


• Support outreach and engagement efforts to meet completion rate targets.


• Participate in relevant population health meetings.

• Perform scheduled metabolic screenings and quality control of lab equipment as needed.


• Provide coverage for care management nursing staff during absences.


• Handle end-of-care processes and other assigned duties supporting care coordination goals.

Qualifications:

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with current state licensure.


• 2 or more years related healthcare experience to include: Inpatient/Outpatient nursing care, medical surgical, psychiatric and pediatric care experience preferred.


• Population health experience preferred

• Knowledge of behavioral health diagnoses, treatment modalities, and medications.

• Strong communication skills, both written and verbal, with the ability to collaborate effectively with multidisciplinary teams.


• Experience in care coordination, case management, and patient advocacy.


• Familiarity with community resources and services for individuals with behavioral health challenges.


• Ability to work independently and manage a caseload effectively.


• Healthcare technology software experience required as well as excellent spreadsheet management and proficiency with Microsoft Office products.

• Compassionate, patient, and empathetic approach to client care.

Educational qualifications:

• Graduate of an accredited school of professional nursing: LPN or higher


• Basic life support certified

Working Conditions:

• This role may involve a combination of in-person, virtual, and telephonic interactions with clients and healthcare providers.


• May require flexible hours to accommodate client needs.


• Occasional travel may be required to visit clients or attend required training courses.