Transition of Care RN
 Mass General Brigham Community Physicians | |
remote work
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 United States, Massachusetts, Somerville | |
| 399 Revolution Drive (Show on map) | |
 Jul 25, 2025 | |
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Across the country, governments, employers, and American families have struggled in the face of rising healthcare costs. Efforts historically have targeted narrow programs and patient populations, and while many have succeeded, healthcare costs continue to rise. It's time to take a radically different approach. A new approach involves putting the patient at the center with the goals of improving value and providing better outcomes at lower cost for patients. The Population Health Management (PHM) department at Mass General Brigham is charged with the challenge to drive better value for patients across Mass General Brigham. To achieve its goals, PHM leverages financial and clinical data to examine opportunities, designs and delivers innovative care models using product development and design thinking disciplines, and leverages problem solving, teamwork, and leadership skills to drive ongoing improvement.
As an integral member of the Population Health Management Operations team, The Transition of Care Nurse Care Manager provides episodic care management for Medicare Shared Savings Program (MSSP) patients from inpatient admission to home. This includes follow up phone calls after discharge, medication reconciliation, and ensuring patient has appropriate follow up appointments scheduled as well as documenting and ensuring all billing requirements are met prior to submitting TCM charges. The Transition of Care Nurse Manager directly interfaces with patients (via phone), Primary Care physicians, pharmacists, care managers, and health care teams involved in patient care as well collaborating with PHM Clinical Operations leadership. The Nurse Care Manager will demonstrate prudent nursing judgment, effective problem-solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task. The Nurse Care Manager will use Mass General Brigham healthcare values to govern decisions, actions, and behaviors. These values govern how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration 1. Manages episodic transitions of care for MSSP patients from inpatient discharge to home as applicable. a. Calls all discharged patients within two business days of discharge and conducts post discharge assessments. b. Works alongside the PHM Clinical Pharmacist to identify and perform Medication Reconciliation for identified patients within the two day follow up phone call. c. Reviews discharge instructions/paperwork prior to call to review with patient any action items needed prior to follow up appointment. d. Facilitate face to face follow-up appointment with their PCP within 7-14 days after discharge (or according to discharge instructions if applicable). e. Document patient interaction (phone calls) in the appropriate patient chart in the electronic medical record. f. Manages and coordinates transitions of care by communicating the care plan to other providers and care managers and applicable practice staff. g. Maintains all documentation according to standards and requirements. h. Ensures all Transitions of Care (TCMs) meet appropriate billing requirements prior to submitting documentation to the billing department per protocol yet TBD. 2. Demonstrates effective teamwork and collaboration with the primary care provider and the care team a. Engages the patient and caregiver as active members of the care team and facilitates an organized and effective, warm hand off for transitions of care back to the patient's medical home (PCP). b. Participates in regular meetings with the providers and the care team to identify opportunities for better transitions or to modify workflows as needed. c. Communicates with other PHM and (Regional Service Operation (RSO) departments and sites to foster collaboration as a 'system' around the patients served. Organizational Responsibilities 1.Demonstrates a positive attitude in dealing with patients, co-workers, and other health care providers and in addressing problems and/or crisis situations. 2.Requires the ability to work independently as well as function effectively within a team-based model of care. 3.Able to establish collegial relationships with physicians, office staff and health care providers in physician's offices, community agencies, hospitals, and other health care facilities. 4.Functioning within the patient centered model of care, demonstrates a commitment to meeting the patient's needs and expectations. 5.Functioning within the team-based model of care 6.Demonstrates initiative and creativity to continuously improve services, work processes, and other activities that affect quality and utilization. 7.Follows applicable policies and procedures for general safety, fire safety, infection control, attendance, punctuality, and appearance. 8.Performs all duties as assigned. Other duties and Responsibilities 1.Assumes accountability for professional growth and development. 2.Acts as a role model for patients by practicing behaviors consistent with the program goals of health promotion and disease prevention. 3.Identifies quality of care issues and reports the concerns to the appropriate person. 4.Collects, prepares, and reports data as directed. 5.Assists in preparation for external audits and surveys as applicable. What You'll Bring 1. Graduate of an accredited school of nursing. Skills For Success 1. Excellent organizational skills. Working Conditions
Mass General Brigham Community Physicians, 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. | |