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Commonwealth Care Alliance Hybrid Registered Nurse (RN) Acute Inpatient Discharge Coordinator, Transitions of Care in Springfield, Massachusetts

Why This Role is Important to Us:

This position is intended to provide clinical case management to CCA member's onsite and telephonic in 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 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 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, and discharge planning

  • Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance. Obtains data as needed. Keeps medical records up to date with member's information. Documents encounters within 48 hours.

  • For Long Term Care patients, performs comprehensive assessments every 6 months or with significant change in condition.

  • For all patients, promotes principles of empowerment, self-efficacy and independance.

  • Other nursing duties as assigned.

  • Provide clinical care to members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.

  • Makes home visits within 48 hours to members discharged from facilities -- as needed.

What We're Looking For:


  • LPN with Certificate and active MA nursing license in good standing or Licensed RN in the Commonwealth of MA with an Associates Degree. BS in Nursing or related degree preferred

  • 2 years discharge planning experience

  • Ability to communicate effectively, verbally and in writing, to all stakeholders

  • Ability to interact with others so as to foster integrity and trust

  • Assumes personal responsibility for her/his workload and is able to work with minimal supervision

  • Must feel comfortable seeing patients in facilities

  • Ability to work as an effective member of the Primary Care team

  • Ability to negotiate level of care discussions

  • Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

  • Ability to work in a variety of computer applications

  • Work in a team based environment

  • Access to personal vehicle and current driver's license

  • Willingness to drive from facility to facility

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.