Care Transitions Navigator - Elder Care (RN)

Fallon Community Health Plan, Inc.; Worcester, Northern (MA, KY); Hybrid; USD 75,000 - 110,000; Full time

Job summary

Fallon Health in Worcester, MA is seeking a Transitions of Care Coordinator (RN) to ensure safe, timely transitions from inpatient settings to home or lower levels of care. You will participate in daily IDT meetings, review patient needs, and coordinate with providers, families, and facilities to optimize outcomes.

The role requires 3–5 years nursing experience with frail or elder populations, MA RN license, strong communication, critical thinking, and knowledge of utilization management.

Qualifications

• BSN or ASN in Nursing required.
• Licensed as Registered Nurse in Massachusetts.
• CCM certification desired.
• Valid driver’s license.

Responsibilities

• Attends daily IDT meetings to discuss inpatients and discharge plans.
• Uses a checklist to ensure a safe transition of care occurs.
• Communicates daily with primary team members to address discharge barriers.
• Participates in family meetings as needed.
• Collaborates with facilities and IDT to ensure safe transitions home.
• Documents care transitions and progress in the electronic health record.

Skills

Interpersonal skills

Analytical skills

Communication skills

Education

BSN or Associate of Science in Nursing

Job description

Fallon Health in Worcester, MA is seeking a Transitions of Care Coordinator (RN) to ensure safe, timely transitions from inpatient settings to home or lower levels of care. You will participate in daily IDT meetings, review patient needs, and coordinate with providers, families, and facilities to optimize outcomes.

The role requires 3–5 years nursing experience with frail or elder populations, MA RN license, strong communication, critical thinking, and knowledge of utilization management.