Nursing Jobs in South Easton, MA
$81,510 - $108,030 / year
Salary $81,510 / yr - $108,030 / yr Overview RN – MDS Coordinator Turn Clinical Expertise Into Better Outcomes. Shape Individualized Care. Make an Impact at West Roxbury. Are you a Registered Nurse (RN) with experience in skilled nursing, Medicare, and the MDS process? Do you have a strong understanding of resident assessment, care planning, and reimbursement methodology — and enjoy bringing clinical knowledge, organization, and collaboration together? We want to talk with you! At West Roxbury Health & Rehabilitation Center , our MDS Coordinator plays an essential role in connecting clinical assessment with quality resident care. As a 76-bed skilled nursing and rehabilitation community in West Roxbury, Massachusetts , we provide Short-Term Rehabilitation and Long-Term Care , along with specialized support including hospice care and respite care . Our interdisciplinary team delivers personalized nursing care, rehabilitation services, and clinical support while creating a welcoming environment focused on resident dignity, comfort, and quality of life. If you're looking for an opportunity to use your nursing expertise beyond the traditional bedside setting while remaining closely connected to resident care, this could be the role for you. Your Expertise Has a Direct Impact on Resident Care The MDS process is about much more than completing assessments. It provides a comprehensive picture of each resident's clinical and functional needs and helps our interdisciplinary team develop a care plan that is individualized, accurate, and responsive to the resident's changing needs. As the RN – MDS Coordinator , you will serve as a key clinical resource for the facility, bringing together information from nursing, rehabilitation, social services, dietary, medical records, residents, families, and other members of the care team. You'll help ensure that assessments are completed accurately and on time, care plans reflect current resident needs, and the facility remains aligned with Medicare, Medicaid, Managed Care, and regulatory requirements. Why This Role Matters Every MDS assessment tells a story. It captures important information about a resident's functional abilities, cognition, mood and behaviors, nutrition, clinical conditions, and overall well-being. That information becomes the foundation for decisions about care. At West Roxbury, your work will help ensure that each resident's unique needs are accurately understood and reflected in their individualized plan of care. Whether supporting a resident working toward greater independence through short-term rehabilitation, someone receiving ongoing long-term care, or a resident and family navigating hospice or respite services, your clinical insight helps guide the care our team provides. This is an opportunity for an experienced RN who enjoys combining clinical judgment with organization, communication, critical thinking, and attention to detail. You'll work closely with leadership and an interdisciplinary team while becoming a key resource in the facility's assessment, care planning, and reimbursement processes. The role may also provide opportunities to support other Elderwood communities and participate in professional development through the Elderwood Learning Center. Your work helps our team: Identify and respond to changing resident needs. Develop meaningful, individualized care plans. Coordinate services across disciplines. Support positive clinical outcomes. Maintain compliance with regulatory requirements. Ensure accurate Medicare, Medicaid, and Managed Care processes. Advocate for residents by making sure their needs are accurately represented. The Support You Need to Succeed At West Roxbury Health & Rehabilitation Center , you won't be working in isolation. You'll have the support of facility nursing leadership as well as Elderwood Administrative Services, including clinical and operational resources designed to help our teams succeed. You'll have the opportunity to collaborate with experienced nursing professionals and access resources in areas including: Clinical operations Quality and regulatory compliance Reimbursement Professional development Nursing leadership Education and training Comprehensive Benefits & More At Elderwood, we believe in supporting the people who support our residents. Our benefits and rewards include: Increased Tuition Reimbursement Program for Clinical Tracks Shift Differentials Full Benefits Package 401(k) with Employer Matching Employee Referral Program Professional Development & Training Opportunities Paid Time Off & Holiday Benefits Additional Compensation Programs Make Your Next Move Count If you're an RN who enjoys looking at the bigger picture, solving problems, coordinating across disciplines, and using clinical expertise to influence the quality of resident care, West Roxbury Health & Rehabilitation Center wants to hear from you. Bring your nursing knowledge. Bring your attention to detail. Bring your commitment to residents. We'll provide the team, resources, and support to help you make an impact. Apply Today for the RN – MDS Coordinator Position at West Roxbury Health & Rehabilitation Center. Responsibilities What You'll Do Lead the MDS & Resident Assessment Process Complete and/or oversee completion of MDS/PPS and OBRA assessments for residents receiving short-term rehabilitation and long-term care. Establish and maintain schedules for required assessments in accordance with federal and state regulations. Ensure MDS assessments, supporting documentation, and related components are accurate, complete, and submitted within required timeframes. Monitor completion of MDS components by other disciplines and address incomplete or untimely information. Review resident records, incidents, accidents, 24-hour reports, and changes in condition to ensure assessments and care plans accurately reflect current needs. Utilize clinical judgment and attention to detail to identify relevant changes in resident status. Develop & Coordinate Individualized Care Plans Initiate, maintain, and update individualized care plans based on resident assessments and changing clinical needs. Ensure care plans identify appropriate interventions and supporting activities designed to achieve the best possible resident outcomes. Conduct care plan conferences with residents, families, and members of the interdisciplinary team. Generate and distribute the monthly care plan calendar. Collaborate closely with nursing, rehabilitation, social services, dietary, medical records, and medical providers. Serve as a clinical resource to members of the care team regarding assessment and care planning requirements. Support Medicare, Medicaid & Reimbursement Complete and/or oversee Medicare PPS assessments for both short-term and long-term care residents. Support accurate documentation related to Medicare, Medicaid, Managed Care, and other reimbursement requirements. Partner with the Business Office to support Medicare eligibility determination and tracking of covered days. Serve as a facility contact and liaison with Managed Care providers regarding authorization and reimbursement. Apply knowledge of PDPM, Case Mix, Medicare/PPS, and reimbursement methodology to support accurate and compliant processes. Collaborate with Medical Records and Therapy staff in preparing documentation for CMS and other entities for pre- and post-payment reviews, ADR requests, and appeals. Promote Compliance, Quality & Accountability Maintain working knowledge of applicable federal and state regulations related to MDS, care planning, Medicare, Medicaid, and resident care. Help ensure documentation and assessment practices remain compliant with regulatory requirements. Identify gaps or delays in the assessment process and communicate concerns to nursing leadership. Support survey readiness and respond appropriately to documentation and assessment-related requests. Maintain knowledge of facility policies, procedures, corporate compliance standards, and professional nursing expectations. Participate in ongoing quality improvement initiatives and other projects as assigned. From Up to Qualifications RN - MDS Coordinator - Qualifications: Current Registered Nurse (RN) license in the state of Massachusetts. Nursing degree from an accredited college or university. Previous experience in a skilled nursing or long-term care environment preferred. Knowledge of the MDS and care planning process. Prior experience with MDS 3.0 scheduling, coding, and submission requirements preferred. Experience with PointClickCare preferred. Knowledge of Patient Driven Payment Model (PDPM) and Case Mix Index (CMI) preferred. Experience with Medicare/PPS, Medicaid, Managed Care, Part A coverage, and reimbursement processes preferred. Strong understanding of resident assessment, care planning, and regulatory requirements. Excellent verbal and written communication skills. Strong organizational and time-management skills with the ability to manage multiple deadlines. Self-motivated, detail-oriented, and committed to accuracy. Ability to collaborate effectively with residents, families, nursing staff, interdisciplinary team members, leadership, and external partners. A willingness to learn and develop — we're open to training the right candidate with strong clinical experience and the ability to grow into the MDS role. This position requires regular interaction with residents, coworkers, visitors, and/or supervisors. In order to ensure a safe work environment for residents, coworkers, visitors, and/or supervisors of the Company, and to permit unfettered communication between the employee and those residents, coworkers, visitors, and supervisors, this position requires that the employee be able to read, write, speak, and understand the English language at an intermediate or more advanced level. EOE Statement WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. 
$95,000 - $101,920 / year
Join our team at Heritage Hills Rehabilitation and Healthcare Center as a Evening Nurse Supervisor. Proudly supported by Marquis Health Consulting Services Full-time, (Monday - Friday, 3:00PM-11:00PM) Range $95,000.00 -$101,920.00 annually At Heritage Hills Rehabilitation and Healthcare Center, we believe that strong clinical leadership, teamwork, and accountability are essential to delivering safe, high-quality resident care. Guided by our core values of Passion, Respect, and Excellence , the Nurse Supervisor provides clinical oversight, leadership, and support to nursing staff while ensuring residents receive consistent, compassionate, and compliant care. Responsibilities for Nurse Supervisor: Provide clinical leadership and supervision to nursing staff to ensure high-quality resident care. Oversee daily nursing operations to promote safe, effective, and person-centered care delivery. Monitor staff performance and provide guidance, coaching, and support as needed. Ensure compliance with all applicable laws, regulations, and facility policies governing nursing care. Assist in coordinating resident care plans and ensuring timely communication across interdisciplinary teams. Support accurate and timely documentation in accordance with clinical standards and regulatory requirements. Respond to clinical concerns and assist in resolving issues involving residents, families, and staff. Participate in quality improvement initiatives and support facility-wide clinical goals. Qualifications for Nurse Supervisor: Must possess a current, unencumbered, active RN or LPN license in the state of Rhode Island. Valid BLS Certification (CPR) required. Minimum of five (5) years of nursing experience in a hospital, nursing home, or other healthcare setting, with at least one (1) to two (2) years in a supervisory role. Strong knowledge of nursing practices, procedures, and applicable laws, regulations, and guidelines for nursing care centers. Effective communication skills with the ability to interact professionally with residents, families, staff, and external agencies. Demonstrated leadership and supervisory skills with the ability to guide, support, and collaborate with team members. Ability to work collaboratively while maintaining accountability and high standards of care. Our Core Values in Action Passion – Leading with commitment and compassion to ensure residents receive safe, attentive, and high-quality nursing care. Respect – Treating residents, families, and team members with dignity, professionalism, and fairness in every interaction. Excellence – Upholding the highest clinical standards through strong leadership, accountability, and continuous improvement. Benefits for Nurse Supervisor: Tuition reimbursement Employee referral bonus Health, vision, and dental benefits 401(k) with match Employee engagement and culture committee Company-sponsored life insurance Employee assistance program (EAP) resources Join our team at Heritage Hills Rehabilitation and Healthcare Center, a 100-bed Sub-Acute, and Long-Term Care facility where compassion and quality care are at the heart of everything we do. Our facility is thoughtfully designed with beautiful common spaces, creating a welcoming, home-like environment not only for our residents but also for our staff. We believe in fostering a positive and supportive workplace where employees feel valued, respected, and empowered to make a difference. Here, you'll be part of a collaborative and dedicated team that prioritizes professional growth, work-life balance, and a culture of appreciation. If you're passionate about providing exceptional care in a warm, inclusive setting, we would love for you to grow your career with us. The facility provides equal employment opportunities to all applicants and employees and prohibits discrimination and harassment of any kind. We do not discriminate based on race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by federal, state, or local law. All qualified applicants are encouraged to apply. 
$81,510 - $108,030 / year
Salary $81,510 / yr - $108,030 / yr Overview RN – MDS Coordinator Turn Clinical Expertise Into Better Outcomes. Shape Individualized Care. Make an Impact at Mattapan. Are you a Registered Nurse (RN) with experience in skilled nursing, Medicare, and the MDS process? Do you have a strong understanding of resident assessment, care planning, and reimbursement methodology — and enjoy bringing clinical knowledge, organization, and collaboration together? We want to talk with you. At Mattapan Health & Rehabilitation Center , our MDS Coordinator plays an essential role in connecting clinical assessment with quality resident care. As an 85-bed skilled nursing and rehabilitation community offering Short-Term Rehabilitation and Long-Term Care , our team works together to help each resident achieve the best possible outcomes while maintaining dignity, independence, comfort, and quality of life. If you're looking for an opportunity to use your nursing expertise beyond the traditional bedside setting while remaining closely connected to resident care, this could be the role for you. Your Expertise Has a Direct Impact on Resident Care The MDS process is about much more than completing assessments. It provides a comprehensive picture of each resident's clinical and functional needs and helps our interdisciplinary team develop a care plan that is individualized, accurate, and responsive to the resident's changing needs. As the RN – MDS Coordinator , you will serve as a key clinical resource for the facility, bringing together information from nursing, rehabilitation, social services, dietary, medical records, residents, families, and other members of the care team. You'll help ensure that assessments are completed accurately and on time, care plans reflect current resident needs, and the facility remains aligned with Medicare, Medicaid, Managed Care, and regulatory requirements. Why This Role Matters Every MDS assessment tells a story. It captures important information about a resident's functional abilities, cognition, mood and behaviors, nutrition, clinical conditions, and overall well-being. That information becomes the foundation for decisions about care. This is an opportunity for an experienced RN who enjoys combining clinical judgment with organization, communication, critical thinking, and attention to detail. You'll work closely with leadership and an interdisciplinary team while becoming a key resource in the facility's assessment, care planning, and reimbursement processes. The role may also provide opportunities to support other Elderwood communities and participate in professional development through the Elderwood Learning Center. Your work helps our team: Identify and respond to changing resident needs. Develop meaningful, individualized care plans. Coordinate services across disciplines. Support positive clinical outcomes. Maintain compliance with regulatory requirements. Ensure accurate Medicare, Medicaid, and Managed Care processes. Advocate for residents by making sure their needs are accurately represented. The Support You Need to Succeed At Mattapan Health & Rehabilitation Center, you won't be working in isolation. You'll have the support of facility nursing leadership as well as Elderwood Administrative Services , including clinical and operational resources designed to help our teams succeed. You'll have the opportunity to collaborate with experienced nursing professionals and access resources in areas including: Clinical operations Quality and regulatory compliance Reimbursement Professional development Nursing leadership Education and training Comprehensive Benefits & More At Elderwood, we believe in supporting the people who support our residents. Our benefits and rewards include: Increased Tuition Reimbursement Program for Clinical Tracks Shift Differentials Full Benefits Package 401(k) with Employer Matching Employee Referral Program Professional Development & Training Opportunities Paid Time Off & Holiday Benefits Additional Compensation Programs Make Your Next Move Count If you're an RN who enjoys looking at the bigger picture, solving problems, coordinating across disciplines, and using clinical expertise to influence the quality of resident care, Mattapan Health & Rehabilitation Center wants to hear from you. Bring your nursing knowledge. Bring your attention to detail. Bring your commitment to residents. We'll provide the team, resources, and support to help you make an impact. Apply Today for the RN – MDS Coordinator Position at Mattapan Health & Rehabilitation Center. Responsibilities What You'll Do Lead the MDS & Resident Assessment Process Complete and/or oversee completion of MDS/PPS and OBRA assessments for residents receiving short-term rehabilitation and long-term care. Establish and maintain schedules for required assessments in accordance with federal and state regulations. Ensure MDS assessments, supporting documentation, and related components are accurate, complete, and submitted within required timeframes. Monitor completion of MDS components by other disciplines and address incomplete or untimely information. Review resident records, incidents, accidents, 24-hour reports, and changes in condition to ensure assessments and care plans accurately reflect current needs. Utilize clinical judgment and attention to detail to identify relevant changes in resident status. Develop & Coordinate Individualized Care Plans Initiate, maintain, and update individualized care plans based on resident assessments and changing clinical needs. Ensure care plans identify appropriate interventions and supporting activities designed to achieve the best possible resident outcomes. Conduct care plan conferences with residents, families, and members of the interdisciplinary team. Generate and distribute the monthly care plan calendar. Collaborate closely with nursing, rehabilitation, social services, dietary, medical records, and medical providers. Serve as a clinical resource to members of the care team regarding assessment and care planning requirements. Support Medicare, Medicaid & Reimbursement Complete and/or oversee Medicare PPS assessments for both short-term and long-term care residents. Support accurate documentation related to Medicare, Medicaid, Managed Care, and other reimbursement requirements. Partner with the Business Office to support Medicare eligibility determination and tracking of covered days. Serve as a facility contact and liaison with Managed Care providers regarding authorization and reimbursement. Apply knowledge of PDPM, Case Mix, Medicare/PPS, and reimbursement methodology to support accurate and compliant processes. Collaborate with Medical Records and Therapy staff in preparing documentation for CMS and other entities for pre- and post-payment reviews, ADR requests, and appeals. Promote Compliance, Quality & Accountability Maintain working knowledge of applicable federal and state regulations related to MDS, care planning, Medicare, Medicaid, and resident care. Help ensure documentation and assessment practices remain compliant with regulatory requirements. Identify gaps or delays in the assessment process and communicate concerns to nursing leadership. Support survey readiness and respond appropriately to documentation and assessment-related requests. Maintain knowledge of facility policies, procedures, corporate compliance standards, and professional nursing expectations. Participate in ongoing quality improvement initiatives and other projects as assigned. From Up to Qualifications RN - MDS Coordinator - Qualifications: Current Registered Nurse (RN) license in the state of Massachusetts. Nursing degree from an accredited college or university. Previous experience in a skilled nursing or long-term care environment preferred. Knowledge of the MDS and care planning process. Prior experience with MDS 3.0 scheduling, coding, and submission requirements preferred. Experience with PointClickCare preferred. Knowledge of Patient Driven Payment Model (PDPM) and Case Mix Index (CMI) preferred. Experience with Medicare/PPS, Medicaid, Managed Care, Part A coverage, and reimbursement processes preferred. Strong understanding of resident assessment, care planning, and regulatory requirements. Excellent verbal and written communication skills. Strong organizational and time-management skills with the ability to manage multiple deadlines. Self-motivated, detail-oriented, and committed to accuracy. Ability to collaborate effectively with residents, families, nursing staff, interdisciplinary team members, leadership, and external partners. A willingness to learn and develop — we're open to training the right candidate with strong clinical experience and the ability to grow into the MDS role. This position requires regular interaction with residents, coworkers, visitors, and/or supervisors. In order to ensure a safe work environment for residents, coworkers, visitors, and/or supervisors of the Company, and to permit unfettered communication between the employee and those residents, coworkers, visitors, and supervisors, this position requires that the employee be able to read, write, speak, and understand the English language at an intermediate or more advanced level. EOE Statement WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. 
$107,000 - $224,123 / year
If you are an existing employee of South Shore Health then please apply through the internal career site. Requisition Number: R-23332 Facility: LOC0010 - Health Express-Weymouth330 Washington Street Weymouth, MA 02188 Department Name: HXP Administration Status: Part time Budgeted Hours: 0 Shift: Varied Shifts (United States of America) Under the general guidance of the Hospitalist Director the Nurse Practitioner will evaluate, diagnose and treat patients following written guidelines approved by the Department of Medicine. As a Hospital Medicine Provider at SSH, you will report, through the Hospitalist Program leadership team including the Lead APC’s and Program Director. You will have such duties and responsibilities as are set forth below and as may be reasonably requested by SSH from time to time. You shall perform the medical services faithfully, with due diligence and efficiency, to the best of your ability, and in accordance with the applicable standards of your profession, canons of professional ethics and all laws and SSH policies in effect from time to time. SSH recognizes that teamwork and flexibility are essential to providing 24-hour per day patient-centered care. SSH expects you to be respectful of your patients, other health care providers, and the physicians and staff of SSH. You shall be professional at all times and adhere to HIPAA standards with regard to maintaining confidentiality of patient information. You will have several different roles as a SSH Hospital Medicine Provider. These roles include admitting, rounding, and performing consults at the request of other providers. Regardless of role, you will be required to use approved SSH patient care treatment plans and order sets, when appropriate. Compensation Pay Range: $107,000.00 - $224,123.00 Essential Functions: Obtains a detailed and accurate medical history and performs a comprehensive physical exam for patients admitted to the Hospital. Orders necessary diagnostic tests, consultations and procedures as indicated or requested by the Hospital Medicine Consultant or attending physician. Identifies and manages chronic medical conditions and provides continuous care to hospitalized inpatients. Has familiarity with current guidelines regarding the assessment of the risk of a perioperative cardiovascular event for pre-operative patients (such as RCRI, and ACS-NSQIP) and pre-operative medical optimization. Prescribes medications, as necessary. Writes orders in accordance with current practice guidelines. Writes complete and comprehensive notes on all patients using appropriate electronic systems consistent with Hospital policy. Facilitates timely care, as necessary. Actively participates in the South Shore Health System readmission reduction efforts. Reviews the care of each patient with the attending physician and other consultative services. Maintains communications with referring physicians. Collaborates with the patient care team (physicians, nurses, PT/OT, case management) to develop and facilitate care plan. Proactively manages patients to prevent complications. Provides urgent evaluation to patients with changes in clinical status. Prepares patients for discharge, including patient and family discharge teaching, continuing care and rehabilitation arrangements in conjunction with Nursing and Care Progression, writing discharge prescriptions, and confirming primary care or referring physician follow-up. Prepares formal discharge summaries for or with Hospitalist. Possess the maturity, self-confidence, and ability to follow complex patient management plans as directed by the attending physician. Eligible for state and federally controlled substances registration. Demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned unit. Time Management: Exceptional organizational skills and ability to organize time and priorities effectively, asking for direction when appropriate. Flexibility to handle multiple tasks and deadline pressures. Quality Improvement: Skills to work efficiently and effectively and strive to do so in all aspects of position. JOB REQUIREMENTS Minimum Education - This position is a licensed independent practitioner credentialed through the Medical Staff Services Office Completion of Advanced Physician Assistant or Nurse Practitioner training program from an accredited institution. All licensure re-certifications, as required. Minimum Work Experience 2 years of Acute Medicine experience, preferred. Required Licenses / Registrations Nurse Practitioner - Board of Registration in Nursing (Massachusetts) Required Classes/Skills - ACLS - Advanced Cardiac Life Support Required additional Knowledge, and Abilities Requires DEAx number for the ability to prescribe Buprenorphine/Suboxone Demonstrated history of proficiency in the delivery of medical care to adult patients. Demonstrated successful completion of the SSH Credentialing process. Hours M-F 9am - 7pm; Sat-Sun 9am - 4pm Responsibilities if Required: Education if Required: License/Registration/Certification Requirements: ACLS (AHA) Advanced Cardiac Life Support Certification - American Heart Association (AHA) (Including courses offered through SSH), Certified Nurse Practitioner - Board of Registration in Nursing (Massachusetts) $58,656 - $142,448.80 / year
Site: Mass General Brigham Community Physicians, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary 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) and Medicaid ACO 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. Primary Responsibilities: 1. Manages episodic transitions of care for Medicare Risk and Medicaid risk 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. Qualifications Qualifications Required: Associate’s Degree Nursing (ASN) or Bachelor’s Degree Nursing (BSN). RN License for State of MA. 3+ years of experience in hospital, health plan or community case management or utilization management role. Care management or home care background. Managed Care or previous healthcare reimbursement knowledge. Preferred: Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. Certification in Case Management (CCM) and/or other applicable professional certification preferred. Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare. Bedside nursing experience. Additional Skills, Knowledge and Abilities: - Excellent organizational skills. - Excellent oral, written, and telephonic skills and abilities. - Critical thinking and problem-solving ability. - Demonstrated ability to present and speak in front of groups. -Demonstrated competency working with health care setting computer systems. -Competence in Microsoft Word, Excel and PowerPoint. -Ability to work effectively with physicians and their staff in a physician practice setting. -Ability to work a flexible schedule including some required evenings or early mornings. -Knowledge of levels of care and the continuum of health care services. -Ability to handle routine work, unexpected priorities, and multi-task. -Requires autonomy in decision making using sound judgment based upon factual information, clinical experience and nursing process. -Ability to work with various practice sites. Additional Job Details (if applicable) Schedule and Work Model Full-Time Saturday through Wednesday, standard business hours (approximately 8:30am-5pm ET), with some flexibility with hours on weekends. Remote with ability to travel to Assembly Row in Somerville, MA for team building, best practice sharing meetings and/or events. As a remote employee, must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. 