TCL Complex Care Nurse Coordinator, RN (Remote Option)

Office Location: Remote Option; Available for any of Partners' NC locations Projected Hiring Range: Depending on Experience Closing Date: Open Until Filled Primary Purpose of Position: The TCL Complex Care Nurse Coordinator’s primary objective is to gather Behavioral Health and Medical assessment information on eligible members transitioning from Adult Care Homes. This position will provide assessment of the members medical, behavioral health, and functional needs prior to transitioning to the community to provide recommendations to the members treatment team. This position will evaluate medical and behavioral health information provided for each member. This position works with TCL members currently in adult care homes, adult care home staff, Primary Care Doctor, Specialist, family members, service providers and other medical professional to provide informed assessments and recommendations to the members treatment team. This position will assist in coordinating additional medical services and supports as needed. This position will work collaboratively with In-Reach Staff, Transition Coordinators, Care Managers, Service Providers, and Medical Providers. This is a mobile position that will require working in various locations throughout and beyond Partners catchment area.

Complex Care Nurse to assigned TCL individuals who may have identified needs with behavioral health, physical health, co-occurring, co-morbid or multi-morbid conditions. Complete Medical, Psychosocial, functional assessments. Review assessments and medical records to provide recommendations for services and treatment. Identify disqualifying health conditions, or conditions that will need specific services recommendations if the individual is living in the community. Collaborates with Complex Care Staff to provide integrated care. Educate individuals and referral entities about TCL. Coordinates and gathers assessment information from providers, and other resources. Review medical documentation. Coordinates with Behavioral Health and Medical service providers to ensure additional assessments are completed. Works with referral entities to address and assess the needs of the individuals, educate on appropriate services and levels of care as needed. Identifies gaps in services and intervenes to ensure that the individual receives appropriate care. Ensures that services for the individual are identified and coordinated across the LME/MCO’s system and with other systems, including primary care. Provide members with information on community based services in order for them to make an informed choice. Assures data is tracked and all reporting requirements are met. Develop clear documentation on each individual. Track number of assessment and where the individual went to live. Other specific functions as they relate to Diversion, In-Reach, Transition Process and Post-Transition responsibilities as indicated from DMA/DMH. Performs related tasks as required. Collaboration: Collaborates with other members of TCL team in reviewing information, providing clinical oversight, to determine eligibility within established time frames. Serves as a collaborative partner in identifying system barriers. Manages and facilitates meetings with community stakeholders as appropriate to TCL. Works in partnership with other LME/MCO departments to address identified needs within the catchment area.