Transitional Care RN, Primary Care

Site: Mass General Brigham Incorporated

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

The Mass General Brigham Medical Group is a system-led operating entity formed by Mass General Brigham to deliver high quality, low cost, innovative community-based ambulatory care. This work stems from Mass General Brigham’s unified system strategy to bring health care closer to patients while lowering total health care costs. The Medical Group provides a wide range of offerings, including primary care, specialty care, behavioral and mental health, and urgent care, both digitally as well as at physical locations in Massachusetts, New Hampshire, and Maine. The group also offers outpatient surgery and endoscopy, imaging, cardiac testing, and infusion. We share the commitment to delivering a coordinated and comprehensive experience across all locations, ensuring the appropriate level of care is available to every patient across our care delivery sites.

We are constantly aiming to improve access for patients and to meet the evolving health care needs of the communities we serve. Primary care is all about relationship-building! We pride ourselves on our true patient-centered medical home model for our patient’s care. The whole team really gets to know our patients to ensure that they are receiving exceptional, personalized care in a comfortable, friendly atmosphere.

Job Summary

We are seeking a 36-hour Transitional Care Nurse Case Manager to join our fully remote team, working Monday through Friday, 8:00 AM – 4:30 PM.

In this role, you will spend your day on the phone, reaching out to patients discharged from hospitals, rehabs, and emergency rooms, collecting medical history, performing clinical screenings, and ensuring they are connected with their primary care providers. Calls are often 45 minutes or longer and require detailed documentation in Epic. The ideal candidate will have at least an Associate’s degree in Nursing, with a primary care or hospital nursing background, be comfortable working autonomously, and be highly organized and skilled at phone-based clinical care. Epic experience is a plus.

Serves as a core member of the care team coordinates and supports healthcare within the facility, and coordinates referrals for services outside the clinic. Provides outreach and enrollment services to meet eligibility requirements of the program and surrounding counties. Ensures coordination and planning, including community and family support. Focuses on the development and coordination of community service plans. Partners with service providers, families, and patients to create a plan of healthcare and identify additional service providers.

Does this position require Patient Care? Yes

Essential Functions

-Client Assessments and Planning

-Modify patient treatment plans as indicated by patients' responses and conditions.

-Prepare patient/family for discharge

-Communicates with third party payers to obtain necessary authorization for reimbursement of services.

-Review cases with medical directors on challenging cases as needed

-Defines care goals of patients by providing education, information, and direction to each individual and family.

-Maintain accurate, detailed reports and records.

-Communicates with third party payers to obtain necessary authorization for reimbursement of services.

Qualifications

Education

Associate's Degree Nursing required or Bachelor's Degree Nursing preferred

Can this role accept experience in lieu of a degree?

No

Licenses and Credentials

Registered Nurse [RN - State License] required

Basic Life Support [BLS Certification] preferred

Experience

Case management, utilization review, or discharge planning experience 2-3 years preferred

Knowledge, Skills and Abilities

- Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.

- Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.

- Ability to establish strong rapport and relationships with patients and staff.

- Proficient in Microsoft Office and industry related software programs.

- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

- Ability to maintain client and staff confidentiality.

- Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care.

- Knowledge of Healthcare and Managed Care preferred.

Additional Job Details (if applicable)

Remote Type

Remote

Work Location

123 Main Street

Scheduled Weekly Hours

36

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$58,656.00 - $142,448.80/Annual

Grade

98TEMP

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

0100 Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.