RN Transitions of Care Coordinator
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Job Location:
Somerville, NJ - USA
Monthly Salary:
$ 58656 - 142448
Posted on:
02-11-2025
Vacancies:
1 Vacancy
Job Summary
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Team: Whole HealthCare Duals Mass General Brigham Health Plan
Hybrid: Required to travel in the community
Primarily serves enrollees in the One Care and Senior Care Options (SCO) programs.
Onsite to assess member patient following member (MGB hospital and facility or nursing home)
Working with interdisciplinary team and liaison with all facilities. Assists with discharge planning before member goes back into community.
Job Summary
The OpportunityMass General Brigham is hiring two Transitions of Care Coordinators to work as part of an interdisciplinary care team dedicated to supporting enrollees and their families in navigating the healthcare system through effective planning and coordination of care transitions.
This role will primarily serve enrollees in the One Care and Senior Care Options (SCO) programs.
The Transitions of Care Coordinator is a Registered Nurse who acts as the primary liaison for each enrollee throughout transitions between care settings.
This role involves close collaboration with the enrollees Interdisciplinary Care Team (ICT) Lead to facilitate discharge planning to appropriate settings and oversee transition processes engaging the ICTincluding the Long-Term Services Coordinator (LTSC) and Geriatric Support Services Coordinator (GSSC) as needed. The coordinator conducts assessments of post-discharge and post-transition needs presents suitable options to enrollees and their caregivers develops individualized care plans and ensures thorough documentation of all assessment updates.
This position is integral to reducing hospital readmissions improving continuity of care and providing essential support to enrollees and their families at critical points in their healthcare journey. This position requires a hybrid work model including practice-based responsibilities remote work and facility or community visits as needed.
The population of focus will primarily include enrollees residing in Essex Middlesex Suffolk Norfolk Plymouth Bristol Dukes and Nantucket counties.
This positions responsibilities and caseload may be adjusted based on enrollee enrollment trends.
Qualifications
What Youll Do
- Collaborates regularly with the Interdisciplinary Care Team (ICT) to review inpatient cases recommend discharge plans and support individualized enrollee-centered care plans.
- Conducts comprehensive assessments of enrollees and families to evaluate physical psychosocial behavioral and environmental needs identifying barriers and service requirements for successful care transitions.
- Develops and implements discharge plans including medication management follow-up appointments and referrals to post-acute services such as home health hospice and rehabilitation.
- Coordinates and facilitates safe timely transitions across care settings by partnering with healthcare facilities providers and community-based organizations.
- Participates in family and case management meetings to support care coordination address barriers and align care goals.
- Identifies and arranges essential support services like food security programs home care and visiting nurse services to ensure continuity of care.
- Educates enrollees and families on diagnoses care plans medications and community resources to promote informed decision-making and self-management post-discharge.
- Ensures timely accurate communication with ICT maintains regular status updates documents care interventions using electronic medical records and complies with regulatory policies.
- Manages a panel of admitted enrollees conducts utilization reviews for inpatient and skilled nursing services ensures adherence to Dual Special Needs Plan (DSNP) regulations conducts facility/community visits and performs additional duties as assigned.
Qualifications to be considered
- Associates Degree Nursing required
- Bachelors Degree Nursing preferred
Certified Case Management Preferred
- Can this role consider or accept experience in lieu of a degree No
- Registered Nurse RN - MA State License
- Basic Life Support BLS Certification
- Case management utilization review or discharge planning experience 2-3 years preferred
Minimum of 3-5 years experience in health plan or community case management
Valid Drivers License and reliable transportation
Experience with community case management Transitions of Care and/or Medicare and Medicaid preferred
Bilingual highly preferred: Bilingual; Spanish Portuguese French and/or Chinese
Skills for Success
- Demonstrates competency with multiple healthcare computer platforms (EPIC experience a plus) and the ability to work effectively in complex fast-paced medical environments across multiple practice locations.
- Experienced in working with individuals with complex medical behavioral and social needs utilizing knowledge of healthcare and community services to assist enrollees effectively.
- Strong communication interpersonal and relationship-building skills to engage enrollees interdisciplinary teams providers and staff promoting Population Health initiatives with excellent oral written and telephonic abilities.
- Exhibits critical thinking problem-solving skills and autonomy in decision-making while effectively managing routine work triaging and reprioritizing as needed with strong organizational skills.
- Comfortable with change and adaptable demonstrating flexibility to pivot and engage in continuous process improvement activities.
- Works independently yet contributes to a collaborative team environment balancing autonomy with teamwork to support organizational goals.
- Active RN license in good standing with meeting all continued education requirements
Additional Job Details (if applicable)
Working Model Required
- M-F Eastern Business Hours required 830a-5pm ET
- Onsite Practice-based remote work and enrollee in-person home and community visits
- Weekly multiple days in field needed will vary
- Reliable transportation and valid drivers license required
- Must be local ideally in Eastern MA. Community capable with autonomy to build own schedule to accommodate members needs. With flexibility required based on member needs
- Must be flexible for training field work and business needs this can very per week in person as well as telephonic or virtual assessments are possible.
- Field work may be increased as the program launches
- Remote working days require stable quiet secure compliant working station using MGB provided equipment and Teams Video access
Our goal will be to geographically align employees this depends on residence and can vary based on business needs member enrollment and team staffing.
Employee must accommodate the hybrid work model including practice-based remote work and enrollee in-person home and community visits.
The population will primarily include enrollees residing in Essex Middlesex Suffolk Norfolk Plymouth Bristol Dukes and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollee enrollment trends.
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$58656.00 - $142448.80/AnnualGrade
98TEMPEEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
IC
Key Skills
- Senior Care
- Hoyer Lift
- Medical office experience
- Dementia Care
- Home Care
- Nursing
- Alzheimers Care
- Administrative Experience
- Meal Preparation
- Medication Administration
- Memory Care
- Tube Feeding
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
