3315367 - Full-time

Are you a dedicated and experienced nurse with a passion for improving patient care and driving positive health outcomes? ThePopulation Health Management (PHM)department at Mass General Brigham invites you to bring your expertise to a dynamic team committed to innovative care models that enhance patient value across our system.

Why Join Mass General Brigham?

At PHM, we use advanced data insights and collaborative problem-solving to transform care delivery. Our work fosters leadership, innovation, and continuous improvement, ensuring the best outcomes for the communities we serve.

About the Role

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.

Schedule/Location:

As a hybrid opportunity, the position is primarilyremote. However, there will be monthly meetings (1-2x per month) on-site at Assembly Row located at: 399 Revolution Drive, Somerville, MA 02145.

Due to the hybrid nature of the role, we ensure that our employees receive required technology and training to be proficient and independently productive in all job responsibilities regardless of work location. Employees are responsible for designating a workspace within the remote work location that is private, safe, ergonomic, and free from distractions for all hours worked.

Mass General Brigham 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.

Mass General Brigham 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.