Transitions of Care Nurse at Commonwealth Care Alliance in Boston, Massachusetts

Job Description:

Why This Role is Important to Us
The Transitions of Care Nurse provides clinical case management to CCA member's onsite and telephonic that are assigned to facilities including hospitals, skilled nursing facilities, nursing homes, rehab hospitals or long-term acute care hospitals. Interfaces with all other members of the patient's care team to determine level of care and to coordinate discharge planning.

What We're Looking For

Minimum Education Required: Bachelor's Degree in Nursing or 2-5 years of Nursing Experience Preferred

Education Experience: BS in Nursing or related degree preferred

Minimum Years' Experience Required: 2 years Registered Nurse or LPN license in the Commonwealth of Massachusetts

BLS Certified

Ability to work in a variety of computer applications

Work in a team based environment

Actual Work Location
2 Avenue de Lafayette, Boston, Massachusetts 02111-1750

All Locations
Lafayette City Center

Exempt / Not Exempt
Exempt




What You'll Be Doing

On-site presence and telephonic coverage at assigned hospitals, skilled nursing facilities and long-term care facilities where there are CCA members admitted

. * Utilizes clinical criteria including InterQual to determine level of care decisions

* Authorizes and makes service decisions based on member's needs including requests for rehab or referral to outside specialists. Utilizes CCA resources, clinical decision support tools and the primary care team to help inform decision-making.

* Works collaboratively with attending MD, NP at facility and CCA Transitions of Care Unit to determine and communicate appropriate level of care.

* Works with facility staff to identify and coordinate care plans and discharge plans

* Oversees care provided in assigned facility. Addresses concerns as they arise. Detects/reports quality of care concerns. Participates in resolution and recommends process improvements.

* Facilitates communication between facility team, member, family and primary care team as needed.

* Actively participates in care planning meetings; family meetings; discharge planning.

* Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance. Obtains data as needed.

Apply Now