Transitions of Care Coordinator

Fallon Community Health Plan, Inc.; Worcester, Northern (MA, KY); On-site; USD 75,000 - 110,000; Full time

Job summary

Fallon Health in Worcester, MA is seeking a Transitions of Care Coordinator (RN) to ensure safe, timely transitions from inpatient settings to home or lower levels of care. You will participate in daily IDT meetings, review patient needs, and coordinate with providers, families, and facilities to optimize outcomes.

The role requires 3–5 years nursing experience with frail or elder populations, MA RN license, strong communication, critical thinking, and knowledge of utilization management.

Qualifications

• BSN or ASN in Nursing required.
• Licensed as Registered Nurse in Massachusetts.
• CCM certification desired.
• Valid driver’s license.

Responsibilities

• Attends daily IDT meetings to discuss inpatients and discharge plans.
• Uses a checklist to ensure a safe transition of care occurs.
• Communicates daily with primary team members to address discharge barriers.
• Participates in family meetings as needed.
• Collaborates with facilities and IDT to ensure safe transitions home.
• Documents care transitions and progress in the electronic health record.

Skills

Interpersonal skills

Analytical skills

Communication skills

Education

BSN or Associate of Science in Nursing

Job description

About us:

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique.

Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region.

Brief summary of purpose

The Transitions of Care Coordinator uses a multidisciplinary approach to ensure that SE participant transitions of care to and from inpatient facilities are appropriate, timely, and successful. In collaboration with the SE IDT ascertains that participants are in receipt of high quality cost efficient care and outcomes

Responsibilities

Primary Job Responsibilities

• Attends daily IDT meetings to discuss inpatients and suggest discharge plans
• Utilize a checklist to ensure that the components of a safe transition of care occur
• Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting
• Participates in family meetings as needed
• Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning.
• Collaborate with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting
• Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation
• Acts as a liaison between facilities and IDT members to convey progress
• Access resources out of network to meet participant needs
• Utilize Collective Medical to track transitions in real time
• Supports the fundamental mission of the Summit ElderCare program
• Determines tier of service at subacute facilities
• Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services
• Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals
• Knowledge of managed care, quality, and risk management principles
• Participates in the SE Utilization Committee
• Generate Ad Hoc request when required
• Concurrent and retrospective review utilizing a multitude of systems and electronic records
• Enters authorizations in applicable systems to ensure that claims are adjudicated efficiently
• Documents all inpatient care transitions and case management progress notes within the electronic health record
• Generate Transitions of Care Templates to accurately reflect transitions and level of care
• Track Vendor Denials
• Identify quality/risk factors in continuum of care and report to Medical Director and Quality Team
• Utilize clinical judgement and critical thinking to suggest alternative measures for provision of care

Qualifications

Education

BSN or Associate of Science in Nursing, Bachelor of Science in Nursing.

License/Certifications

Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a Registered Nurse.

Valid Driver’s License

CCM or similar certification desired

Experience

Three to five years nursing experience with one year experience working with a frail or elder population. Recent case management or utilization management experience and knowledge of criteria for medical necessity determination preferred. Must possess strong interpersonal, analytical and communication skills.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Location

US-MA-Worcester

Posted Date

1 day ago (9/8/2026 9�11 AM)