Care Transitions Specialist - Elder Care

Fallon Health; Massachusetts; On-site; USD 98,000 - 102,000; Full time

Job summary

Fallon Health, based in Worcester, MA, seeks a Transitions of Care Coordinator to manage smooth transitions of care for Summit ElderCare participants. The role collaborates with an interdisciplinary team to ensure high-quality, cost-efficient care and successful discharges from inpatient settings.

The coordinator will engage with facilities, families, and care teams to optimize care transitions, utilization, and records, while leveraging real-time tracking tools and adherence to care standards.

Qualifications

• Three to five years nursing experience with one year working with a frail or elder population.
• Recent case management or utilization management experience and knowledge of criteria for medical necessity determination preferred.
• CCM or similar certification desired.

Responsibilities

• Attends daily IDT meetings to discuss inpatients and discharge plans.
• Uses a checklist to ensure a safe transition of care.
• 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.
• Facilitates record exchange for continuity of care and medication reconciliation.
• Acts as a liaison between facilities and IDT to convey progress.
• Utilizes resources out of network to meet participant needs.
• Tracks transitions in real time using Collective Medical.
• Supports the Summit ElderCare program mission.

Skills

Interpersonal skills

Analytical thinking

Communication skills

Education

BSN or ASN in Nursing

Tools

Electronic Health Records (EHR)

Job description

Fallon Health, based in Worcester, MA, seeks a Transitions of Care Coordinator to manage smooth transitions of care for Summit ElderCare participants. The role collaborates with an interdisciplinary team to ensure high-quality, cost-efficient care and successful discharges from inpatient settings.

The coordinator will engage with facilities, families, and care teams to optimize care transitions, utilization, and records, while leveraging real-time tracking tools and adherence to care standards.