Transitions of Care RN Care Manager

About This Role

The Transitions of Care RN Care Manager is responsible for providing episodic care management for Medicare Shared Savings Program and Medicaid ACO patients from inpatient admission to home. This role is ideal for nurses who excel in patient interaction and care coordination.

• Pay: $58,656.00 - $/Annual
• Location:
  
  Somerville, MA
• Facility:
  Mass General Brigham Community Physicians, Inc.
• Schedule:
  
  Full-Time, Monday through Friday, standard business hours (approximately 8:30am-5pm ET)

• Manage episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home.
• Call all discharged patients within two business days of discharge and conduct post-discharge assessments.
• Work alongside the PHM Clinical Pharmacist to identify and perform Medication Reconciliation for identified patients.
• Review discharge instructions/paperwork prior to call to discuss action items needed before follow-up appointment.
• Facilitate face-to-face follow-up appointments with their PCP within 7-14 days after discharge.
• Document patient interactions in the appropriate patient chart in the electronic medical record.
• Manage and coordinate transitions of care by communicating the care plan to other providers and care managers.
• Maintain all documentation according to standards and requirements.
• Ensure all Transitions of Care (TCMs) meet appropriate billing requirements prior to submitting documentation.
• Engage the patient and caregiver as active members of the care team.

• Associate's Degree Nursing (ASN) or Bachelor's Degree Nursing (BSN) required

• 3+ years of experience in hospital, health plan, or community case management or utilization management role required
• Care management or home care background required

• RN License for State of MA required
• Certification in Case Management (CCM) preferred

Mass General Brigham is a leading healthcare provider committed to delivering exceptional patient care. They rely on a wide range of professionals to advance their mission of supporting patient care, research, teaching, and community service.