This position is the central point of review and analysis of all needs of beneficiaries.  This is an integral role within NLCMHA’s Behavioral Health Home (BHH) to support BHH beneficiaries with interventions necessary to improve health outcomes through coordination and integration of health care services across the continuum of care.  This position is responsible for supporting those we serve in recovery, maintaining good mental and physical health, and managing symptoms in support of healthy goals.


ESSENTIAL POSITION FUNCTIONS (listing Position Specific functions first):

  • Assessment of potential beneficiaries’ behavioral and health care needs and readiness to change.
  • Periodic reassessment of each beneficiary’s treatment, outcomes, goals, self-management, health status, and service utilization.
  • Identify and select strategies to implement evidence-based wellness and prevention activities for beneficiaries.
  • Completion of initial care plan development that includes specific health care goals for all beneficiaries and interventions to be completed by BHH, utilizing sound clinical judgment based upon patient needs according to current practice guidelines and best practices.
  • Monitor effectiveness and interventions in care plans and assure changes in physical and mental health needs are updated in the care plan.
  • Communicate and coordinate beneficiary medical services and needs with medical providers, subspecialty providers including mental health and substance use disorder service providers, long term care and hospitals.
  • Initiate and lead patient care team huddles.
  • Receive and review care records, continuity of care documents, and discharge summaries.
  • Provide education regarding health conditions, treatment recommendations, medications, and strategies to implement care plan goals including both clinical and non-clinical needs for beneficiaries.
  • Medication reconciliation and pharmacy coordination as needed for beneficiaries.
  • Responsible for meeting agency performance expectations related to billing.
  • Use of Electronic Health Record (EHR) and other Health Information Technology (HIT) to link services and facilitate communication among team members and provide feedback.
  • Home visits as necessary to ensure stability through transitions.
  • Exchange appropriate information with team members to ensure ongoing services with beneficiaries.
  • Work as part of a multi-disciplinary team include psychiatrist, mental health professional, and other team members to mentor, educate, and support one another.
  • Participate in quality review activities as a member of the clinical team.
  • Practice safety, environmental, and/or infection control methods.
  • Act in a professional manner reflecting the mission and philosophy of NLCMHA.
  • Build and maintains positive working relationships.
  • Attend and participates in staff meetings as required.
  • Other applicable duties as may be assigned.


  • At least 2 years of experience in providing medical care services required, primary care setting preferred.
  • At least 2 years of experience directly related to the duties and responsibilities specified is preferred.


  • Current Licensure in the State of Michigan as a Registered Nurse
  • Must be qualified in Basic Life Support techniques.