RN Care Transitions Specialist - Elder Care (PACE)

Fallon Health; Worcester (MA); On-site; USD 98,000 - 102,000; Full time

Job summary

Fallon Health is seeking a Transitions of Care Coordinator for its Summit ElderCare program in Worcester, MA. The role guides safe, timely transitions from inpatient facilities to home or lesser care settings with a multidisciplinary team.

You will monitor adherence to care plans, coordinate with facilities and IDT members, and manage documentation and records exchange to optimize quality and cost efficiency.

Qualifications

• BSN or Associate of Science in Nursing is required.
• Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a Registered Nurse is required; CCM or similar certification is desired.
• Three to five years nursing experience with frail/elder population; recent case management/utilization management experience preferred.

Responsibilities

• Attend daily IDT meetings to discuss inpatients and discharge plans.
• Collaborate with facilities and IDT to ensure safe, timely transitions between care settings.
• Document all transitions and care management progress in the EHR.
• Generate transition templates and track vendor denials as needed.

Skills

Interpersonal skills

Analytical skills

Communication skills

Nursing experience

Team collaboration

Education

BSN or ASN in Nursing

Job description

Fallon Health is seeking a Transitions of Care Coordinator for its Summit ElderCare program in Worcester, MA. The role guides safe, timely transitions from inpatient facilities to home or lesser care settings with a multidisciplinary team.

You will monitor adherence to care plans, coordinate with facilities and IDT members, and manage documentation and records exchange to optimize quality and cost efficiency.