Behavioral Health Transition Liaison - Registered Nurse

COMMUNITY HEALTH:

Community Health is a primary care network that provides nationally-recognized programs, a focus on wellness, dental, behavioral health and pediatric specialties, walk-in Express Care, a culture of community and quality health care that almost everyone, insured or uninsured, has come to depend on. As an equal opportunity employer, we offer a team-oriented, collaborative work environment for close to 400 employees at eight different locations in Rutland and southern Addison counties. 

ABOUT THE ROLE:

Cares for Community Health patients (adult and pediatric) who present to the emergency department for either substance use and/or behavioral health reasons and addresses their social determinants of health needs. The Behavioral Health Transition Liaison will also assist in the management and coordination of patients that need support in establishing services with a primary care provider and assists the patient in discharge/follow-up planning. The Behavioral Health Transition Liaison will monitor and assist patients for 30 days after discharge from PSIU, psychiatric/addiction facilities, or emergency department. 

FUNCTIONS OF THE POSITION: 

• Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives.  Essential functions are critical or fundamental to the performance of the job.   They are the major functions for which the person in the job is held accountable.  Following are the essential functions of the job.
• Acts as a short-term care coordinator for patients who are transitioning between PSIU, psychiatrics/addiction facilities, or emergency departments.
• Establish relationship with patients who are not currently utilizing primary care to reengage or initiate services.
• Provide follow-up care to patients based on the level of complexity as identified by the behavioral health provider. 
• Will serve as the primary contact for PSIU, psychiatric/addiction facilities, or emergency departments to assist with discharges back to the community.
• Will assure that patients discharged from hospital/psychiatric/addiction facilities have adequate education and knowledge of their medication list and will conduct medication reconciliation.  
• Collaborate with designated discharge planners regarding follow-up care and potential post discharge concerns or barriers that have been identified.  
• Provide follow-up phone calls and any other services post discharge to behavioral health patients that are discharging from an inpatient or residential program. 
• Attend internal and/or external utilization meetings to coordinate care when behavioral health concerns are identified.
• Will provide short term care coordination until a long-term care coordinator is identified. 
• Works with Visiting Nurses, SASH, and Council on Aging, VCCI; various support groups and any other member of the healthcare team or community stakeholders as necessary.
• Act as a resource for medical providers with patients that may be experiencing a mental health emergency. 
• Conduct suicide, social determinants of health, and other behavioral health screenings to develop appropriate follow up plans.
• Provide individual or family supportive counseling when deemed appropriate.
• Assist patients with completing medical/social service documentation. 
• Participate in Behavioral Health meetings and Care Coordination Meetings.
• Will complete designated self-chart audits.
• Will comply with required expectations for consistent documentation of care management services provided.Will collaborate and coordinate care with any potential post discharge concern or barrier that has been identified.
• Will determine frequency of telephone encounters based on specific patient need. 
• Will identify barriers to care (includes social determinants of health) for care managed patients and will reach out to appropriate recourses based on patient needs.  
• May determine at any time that a patient requires a face-to-face visit.
• Will have an identified schedule that they will utilize to follow up with their patients
• Will follow-up with all identified care managed hospital discharge patients that do not keep their appointments and provide additional follow-up based on patient needs. 
• Will assist patients that have been identified as needing intense care/chronic disease management on a short-term basis.
• Will prioritize patients using standard risk stratification tool.

SKILLS REQUIRED FOR SUCCESS:

• Graduate of an accredited RN school of nursing program. 
• Maintains current Vermont State License.
• Documented medical experience with full knowledge of medications and their effects, patient education examination, diagnostic and treatment procedures.
• One year of professional nursing experience preferred, preferably in an office setting.

  HOW WE SUPPORT YOU:

• Work Life Balance
• Generous Time Off
• Medical, dental, and vision insurance.
• Health savings account option.
• Robust 403 (b) retirement savings plan, with employer match and 100% vesting schedule.
• Comprehensive Wellness Program.

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