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Jordan Hospital RN, Case Manager/Continuing Care Coordinator in Plymouth, Massachusetts


  • Identifies continuing care needs through assessment, interdisciplinary care rounds and/or requests.

  • In collaboration with patients, families and community services establishes a coordinated discharge plan based on the patient's transition needs.

  • Coordinates continuing care services to include skilled nursing, durable medical equipment and community services.

  • Interfaces with aftercare providers to ensure smooth transition with the post discharge plan of care.

  • Conducts ongoing assessment to determine the continued need for acute care, and appropriateness/timeliness of treatments/procedures to optimize reimbursement.

  • Collaborates with the UR team regarding level of care determination/LOS.

  • Coordinates continuing care for SDC, ED and other outpatient areas on request.

    It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

    Education/Experience Required:

  • Current MA RN License

  • Bachelor's Degree in Nursing or advanced degree in healthcare preferred.

  • CCM certification preferred.

  • A minimum of 1 year case management experience working independently in an acute or post-acute setting or a minimum of 1 year experience independently coordinating transitions of care in the healthcare setting with knowledge of community resources.

  • Ability to identify appropriateness of patients admission and level of care needs (inpatient and observation) utilizing Interqual criteria.

  • Knowledge of Interqual and Allscripts systems preferred.

  • Strong interpersonal and negotiations skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, fellow employees, and insurance companies.

  • Computer skills, including Microsoft Outlook, Word, Excel and Meditech.

  • Ability to work independently.


  • Massachusetts RN License.