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Transition of Care-Nurse Care Manager, Population Health

Mass General Brigham Medical Group, Inc.
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 01, 2025
As a Transition of Care Nurse Care Manager, you will manage the care of Medicare Shared Savings Program (MSSP) patients transitioning from hospital to home. Your responsibilities include conducting post-discharge assessments, collaborating with pharmacists for medication reconciliation, facilitating follow-up appointments, and ensuring thorough documentation in the electronic medical record. You will also work closely with care teams, practices, and regional operations staff to create seamless transitions for patients. This role provides a unique opportunity to make a meaningful impact on patient care while driving improvements in health outcomes. Key Responsibilities: Post-Discharge Care: Conduct follow-up calls with discharged patients within two business days, review discharge instructions, and schedule follow-up appointments with PCPs within 7-14 days. Medication Reconciliation: Collaborate with clinical pharmacists to ensure accurate and timely medication reviews for patients. Coordination and Documentation: Ensure care plans are communicated effectively to providers, care managers, and practice staff, while maintaining comprehensive documentation in the EMR. Collaboration: Work closely with primary care providers and care teams to streamline care transitions and improve workflows. Compliance: Ensure all Transitions of Care (TCM) meet appropriate billing requirements. Current and unrestricted Registered Nurse (RN) license in the state of Massachusetts. 5 years of relevant nursing experience required Previous experience in a hospital, health plan, or community practice case management role BSN Certification in case management (CCM) or other applicable professional certification preferred. Previous experience working in an ambulatory setting such as a health center or physician's office is preferred. Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare Mass General Brigham Medical Group, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.