About Us

The Population Health Management (PHM) department at Mass General Brigham is dedicated to enhancing patient value across our system. By utilizing financial and clinical data, we identify opportunities and develop innovative care models through product development and design thinking methodologies. Our approach leverages problem-solving, partnership, and leadership skills to drive continuous improvement and deliver exceptional patient outcomes.

Schedule/Location:

As a hybrid opportunity, the position is primarily remote. 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.

The Opportunity:

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.

We are seeking a highly motivated and experienced nurse to join our elite Population Health team.This role offers a unique opportunity to make a meaningful impact on patient care and help drive positive health outcomes.

Primary Responsibilities:

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.

Required:

• Current and unrestricted Registered Nurse (RN) license in the state of Massachusetts.
• 5 years of relevant nursing experience required
• Previous experience in a hospital, health plan, or community practice case management role

Preferred:

• BSN
• Certification in case management (CCM) or other applicable professional certification preferred.
• Previous experience working in an ambulatory setting such as a health center or physician's office is preferred.
• Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare

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.