RN Transitions of Care Coordinator

The Opportunity

Mass General Brigham is hiring two Transitions of Care Coordinators to work as part of an interdisciplinary care team dedicated to supporting enrollees and their families in navigating the healthcare system through effective planning and coordination of care transitions.

This role will primarily serve enrollees in the One Care and Senior Care Options (SCO) programs.

The Transitions of Care Coordinator is a Registered Nurse who acts as the primary liaison for each enrollee throughout transitions between care settings.

This role involves close collaboration with the enrollee's Interdisciplinary Care Team (ICT) Lead to facilitate discharge planning to appropriate settings and oversee transition processes, engaging the ICT-including the Long-Term Services Coordinator (LTSC) and Geriatric Support Services Coordinator (GSSC) as needed. The coordinator conducts assessments of post-discharge and post-transition needs, presents suitable options to enrollees and their caregivers, develops individualized care plans, and ensures thorough documentation of all assessment updates.

This position is integral to reducing hospital readmissions, improving continuity of care, and providing essential support to enrollees and their families at critical points in their healthcare journey. This position requires a hybrid work model, including practice-based responsibilities, remote work, and facility or community visits as needed.

The population of focus will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties.

This position's responsibilities and caseload may be adjusted based on enrollee enrollment trends.

• Collaborates regularly with the Interdisciplinary Care Team (ICT) to review inpatient cases, recommend discharge plans, and support individualized, enrollee-centered care plans.
• Conducts comprehensive assessments of enrollees and families to evaluate physical, psychosocial, behavioral, and environmental needs, identifying barriers and service requirements for successful care transitions.
• Develops and implements discharge plans, including medication management, follow-up appointments, and referrals to post-acute services such as home health, hospice, and rehabilitation.
• Coordinates and facilitates safe, timely transitions across care settings by partnering with healthcare facilities, providers, and community-based organizations.
• Participates in family and case management meetings to support care coordination, address barriers, and align care goals.
• Identifies and arranges essential support services like food security programs, home care, and visiting nurse services to ensure continuity of care.
• Educates enrollees and families on diagnoses, care plans, medications, and community resources to promote informed decision-making and self-management post-discharge.
• Ensures timely, accurate communication with ICT, maintains regular status updates, documents care interventions using electronic medical records, and complies with regulatory policies.
• Manages a panel of admitted enrollees, conducts utilization reviews for inpatient and skilled nursing services, ensures adherence to Dual Special Needs Plan (DSNP) regulations, conducts facility/community visits, and performs additional duties as assigned.

• Associate's Degree Nursing required
• Bachelor's Degree Nursing preferred
• Certified Case Management Preferred
• Can this role consider or accept experience in lieu of a degree? No
• Registered Nurse [RN - MA State License]
• Basic Life Support [BLS Certification]
• Case management, utilization review, or discharge planning experience 2-3 years preferred
• Minimum of 3-5 years' experience in health plan or community case management
• Valid Driver's License and reliable transportation
• Experience with community case management, Transitions of Care, and/or Medicare and Medicaid preferred
• Bilingual highly preferred:
  Bilingual;
  Spanish, Portuguese, French, and/or Chinese

• Demonstrates competency with multiple healthcare computer platforms (EPIC experience a plus) and the ability to work effectively in complex, fast-paced…