Remote Transitions of Care RN Care Manager

Mass General Brigham Community Physicians; Somerville (MA); On-site; USD 59,000 - 142,000; Full time

Job summary

Mass General Brigham Community Physicians, Inc. seeks a Transition of Care Nurse Care Manager to coordinate episodic care for MSSP and Medicaid ACO patients from hospital discharge to home.

This role includes post-discharge calls, medication reconciliation, scheduling follow-ups, and documentation to ensure billing requirements are met, working with PCPs, pharmacists, and care teams. Remote with occasional travel to Assembly Row, Somerville, MA; full-time schedule; 40 hours weekly, and a

Qualifications

• Associate's Degree Nursing (ASN) or Bachelor's Degree Nursing (BSN).
• RN License for State of MA.
• 3+ years of experience in hospital, health plan or community case management or utilization management role.
• Care management or home care background.
• Managed Care or previous healthcare reimbursement knowledge.

Responsibilities

• Manages episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home as applicable.
• Calls all discharged patients within two business days of discharge and conducts post discharge assessments.
• Reviews discharge instructions/paperwork prior to call to review with patient any action items needed prior to follow up appointment.
• Facilitate face to face follow-up appointment with their PCP within 7-14 days after discharge.
• Document patient interaction (phone calls) in the appropriate patient chart in the electronic medical record.

Skills

Excellent organizational skills

Oral and written communication

Telephonic communication

Critical thinking

Problem solving

Team collaboration

Autonomy

Decision making

Education

ASN or BSN

RN License for MA

CCM certification preferred

Tools

Microsoft Word

Excel

PowerPoint

Job description

Mass General Brigham Community Physicians, Inc. seeks a Transition of Care Nurse Care Manager to coordinate episodic care for MSSP and Medicaid ACO patients from hospital discharge to home.

This role includes post-discharge calls, medication reconciliation, scheduling follow-ups, and documentation to ensure billing requirements are met, working with PCPs, pharmacists, and care teams. Remote with occasional travel to Assembly Row, Somerville, MA; full-time schedule; 40 hours weekly, and a