Continuity Nurse- RN

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

Benefits offered by this job

Competitive salary

Medical insurance starts first day

80% premiums covered

Generous time off

Dental and Vision insurance

403b Retirement Plan with employer

Flexible Spending Accounts

Employee Assistance Program

Job summary

Edward M. Kennedy Community Health Center in Worcester, MA is hiring a Continuity Nurse- RN to support post-ED and post-hospital care coordination. You will identify, triage, track, and schedule patients to ensure timely follow-up. You’ll work with the Quality Improvement RN to connect patients with preventive services.

The organization emphasizes teamwork, accountability, and respect. Equal opportunity employer and inclusive of diverse communities.

Qualifications

• Massachusetts RN license is required.
• BLS certification required.
• Minimum 2 years external nursing experience; 1.5 years at Kennedy Community Health.
• Demonstrated experience and/or interest in working with transgender individuals.

Responsibilities

• Reviews admission, discharge, and transition reports to determine appropriate services.
• Develops relationships with hospitals and community partners.
• Contacts patients within 24–72 hours of ED visit or discharge to coordinate follow-up.
• Conducts telehealth visits to provide education and develop post-hospital care plans.
• Coordinates appointments and services with Primary Care Teams.
• Guides patients through the healthcare system and available resources.
• Performs utilization reviews and identifies high-cost/high-utilization cases.
• Participates in quality improvement processes.

Skills

Care coordination

Telehealth

Patient education

Hospital discharge planning

Education

Massachusetts RN License

BLS Certification

Job description

Salary Range: $37.00-40.00/Hour
Final Salary determined on experience, licensure, etc.

Are you looking for a meaningful career? Are you passionate about healthcare in your community? Do you enjoy helping people?

Edward M. Kennedy Community Health Center is one of the largest community health centers in Massachusetts serving Worcester, Framingham, Milford and the surrounding communities. We are a thriving and growing organization, and our team is expanding across sites to support this growth.

Salary Range: $37.00-40.00/Hour
Final Salary determined on experience, licensure, etc.

Are you looking for a meaningful career? Are you passionate about healthcare in your community? Do you enjoy helping people?

Edward M. Kennedy Community Health Center is one of the largest community health centers in Massachusetts serving Worcester, Framingham, Milford and the surrounding communities. We are a thriving and growing organization, and our team is expanding across sites to support this growth.

We are currently hiring a Continuity Nurse- RN, based in Worcester, MA.

The Continuity Nurse supports care coordination for patients following emergency room visits and hospital admissions. This role is responsible for identifying, triaging, tracking, and scheduling patients to help ensure timely follow-up and continuity of care. The Continuity Nurse will also work closely with the Quality Improvement RN to identify and track patients with outstanding preventive care needs and help connect them with appropriate services.

As an employer of choice, our inclusive workplace environment fosters teamwork, accountability and respect and supports the growth and development of each employee. We are an equal opportunity employer and embrace the richness of the cultures of our staff and community. You are a good fit for our team if you’re passionate about helping people live healthier lives and enjoy working in a supportive, team‑based environment.

Essential Functions

• Reviews admission, discharge, and transition reports and patient records to determine appropriate services based on patient needs
• Develops relationships with participating hospitals and community partner organizations
• Contacts patients within 24–72 hours of an ED visit or hospital discharge to assess follow-up needs and coordinate services using the EHR
• Conducts telehealth visits, when appropriate, to provide education and develop post-hospital/ED care plans
• Collaborates with Primary Care Teams to coordinate appointments, services, and address barriers to care
• Helps patients navigate the healthcare system by providing guidance on processes, resources, and available services
• Performs utilization reviews and identifies high-cost/high-utilization cases, recommending opportunities to improve care and reduce costs
• Reviews preventive care gap reports and conducts outreach to high‑risk patients
• Participates in performance improvement initiatives and quality improvement processes

Education and Experience

• Current Massachusetts Registered Nurse (RN) License
• Current Basic Life Support (BLS) certification
• 2 years of external experience, 1.5 years of experience at Kennedy Community Health
• Demonstrated experience and/or interest in working with transgender individuals.

Benefits

• Competitive salary based on related experience
• Medical insurance starts on the first day of employment.
  • Health center pays 80% of medical insurance premiums
  • Includes coverage for all individuals and most family types.
• Generous time off packages
• Dental and Vision insurance
• 403b Retirement Plan with employer match
• Flexible Spending Accounts
• Employee Assistance Program