Continuity Care RN – Post-Discharge & Telehealth

Edward M. Kennedy Community Health Center, Inc; Worcester (MA); On-site; USD 51,000 - 55,000; Full time

Benefits offered by this job

Medical insurance starts day 1

80% premiums covered

Generous time off

Dental and Vision insurance

403b retirement plan with match

Flexible Spending Accounts

Employee Assistance Program

Job summary

Edward M. Kennedy Community Health Center, Inc. in Worcester, MA is hiring a Continuity Nurse (RN) to support care coordination after ED visits and hospital discharges. The role focuses on timely follow-up, arranging services, and education for patients, with collaboration across care teams.

The position requires an MA RN license and BLS, plus 2 years of nursing experience; experience with transgender patients is a plus. Employment includes comprehensive benefits and a competitive hourly rate.

Qualifications

• RN license required in Massachusetts.
• BLS certification required.
• Minimum 2 years external nursing experience; 1.5 years at Kennedy Community Health.
• Experience caring for transgender individuals is preferred.

Responsibilities

• Reviews admission, discharge, and transition reports to determine needed services.
• Coordinates with hospitals and community partners for follow-up.
• Contacts patients within 24–72 hours of ED visit to arrange follow-up.
• Conducts telehealth visits to develop post-hospital/ED care plans.
• Collaborates with Primary Care Teams to coordinate appointments and services.
• Assists patients in navigating the healthcare system and resources.
• Performs utilization reviews to identify high-cost/high-utilization cases.
• Reviews preventive care gap reports and supports outreach.

Skills

Care coordination

Telehealth

Patient follow-up

Quality improvement

Education

Massachusetts RN License

BLS certification

2 years external experience

Experience with transgender care

Tools

EHR

Job description

Edward M. Kennedy Community Health Center, Inc. in Worcester, MA is hiring a Continuity Nurse (RN) to support care coordination after ED visits and hospital discharges. The role focuses on timely follow-up, arranging services, and education for patients, with collaboration across care teams.

The position requires an MA RN license and BLS, plus 2 years of nursing experience; experience with transgender patients is a plus. Employment includes comprehensive benefits and a competitive hourly rate.