You may choose to display a cookie banner on the external site. You must specify the message in the cookie banner and may add a link to a relevant policy. If you are unfamiliar with these requirements, please seek the advice of legal counsel. )* 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* 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 medical environments across multiple practice locations.* Experienced in working with individuals with complex medical, behavioral, and social needs, utilizing knowledge of healthcare and community services to assist enrollees effectively.* Strong communication, interpersonal, and relationship-building skills to engage enrollees, interdisciplinary teams, providers, and staff, promoting Population Health initiatives with excellent oral, written, and telephonic abilities.* Exhibits critical thinking, problem-solving skills, and autonomy in decision-making, while effectively managing routine work, triaging, and reprioritizing as needed with strong organizational skills.* Comfortable with change and adaptable, demonstrating flexibility to pivot and engage in continuous process improvement activities.* Works independently yet contributes to a collaborative team environment, balancing autonomy with teamwork to support organizational goals.* Active RN license, in good standing with meeting all continued education requirements**The population will primarily include enrollees residing in Essex, Middlesex, Suffolk, Norfolk, Plymouth, Bristol, Dukes, and Nantucket counties. The responsibilities and caseload may be adjusted based on enrollee enrollment trends.** ****Combat disease. Hold a hand. Help people. Impact the world.Mass General Brigham is a passionate, welcoming community where minds meet caring hearts.Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world.Built on the legacy of two leading academic medical centers, we’re more than a system—we’re leaders in the practice of medicine. Mass General Brigham is committed to serving the community.We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system.We recognize that increasing value and continuously improving quality are essential to maintaining excellence.
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