Care Navigator: Transitions of Care (Hybrid)

WellSense Health Plan; Boston (MA); Hybrid; USD 70,000 - 101,000; Full time

Benefits offered by this job

Hybrid work

Competitive salary

Excellent benefits

Job summary

WellSense Health Plan seeks a Clinical Care Manager to provide holistic care management across the care continuum, assessing medical and behavioral readiness and developing individualized care plans with measurable goals and ongoing follow-up. The role involves coordinating with a multidisciplinary team, performing assessments, and guiding members to appropriate services and supports.

The position requires travel to conduct in-person transitions-of-care visits and to collaborate with providers,

Qualifications

• Bachelor’s degree in nursing or ADN with relevant work experience.
• 3 years related experience in home health care or managed care organization.
• 3 years clinical experience with members who have multiple, chronic or complex health conditions.
• 2 years in care management, care coordination, and/or discharge planning.

Responsibilities

• Supports programs and clinical best practices to improve health outcomes and prevent hospital readmissions.
• Completes transitional care management assessments and condition-specific assessments.
• Coordinates care transitions with hospitals and community providers.
• Performs medication reconciliation and ensures discharge plan adherence.

Skills

Motivational Interviewing

Oral and written communication

Collaboration

Documentation

Organizational skills

Education

Bachelor’s degree in nursing

ADN (Associate Degree in Nursing)

Tools

Microsoft Office

MS Outlook

MS Word

Job description

WellSense Health Plan seeks a Clinical Care Manager to provide holistic care management across the care continuum, assessing medical and behavioral readiness and developing individualized care plans with measurable goals and ongoing follow-up. The role involves coordinating with a multidisciplinary team, performing assessments, and guiding members to appropriate services and supports.

The position requires travel to conduct in-person transitions-of-care visits and to collaborate with providers,