Behavioral Health Home Registered Nurse Care Manager (BHH RN)

Conduct comprehensive nursing assessments and identify physical health, behavioral health, substance use, preventive care, and social service needs for adults and children enrolled in MaineCare Behavioral Health Home Services. Collaborate with members, families, providers, and community partners to develop and implement individualized Plans of Care, while providing health education, medication support, chronic disease management guidance, and self-management coaching. Coordinate referrals, follow-up care, hospital transitions, and access to healthcare and community resources, monitoring health outcomes and care gaps to support quality improvement. Participate in interdisciplinary team meetings, clinical consultations, and care planning activities to promote coordinated, whole-person care. Maintain accurate and timely documentation while ensuring compliance with MaineCare, HIPAA, nursing standards, and agency policies. Support continuity of care through ongoing member engagement, advocacy, and coordination across healthcare settings.