Continuity Nurse- RN

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

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 Nursesupports 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