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Commonwealth Care Alliance Transitions of Care Nurse in Springfield, Massachusetts

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.

At Commonwealth Care Alliance (CCA), our vision is to lead the way in transforming the nation’s healthcare for individuals with the most significant needs. If being part of a team and working on combined solutions for patients matters to you…keep reading. We may have something to talk about.

At CCA, your role matters. You’ll be joining an organization that is mission driven, believes in internal mobility, has excellent benefits (see below) and embraces innovation when it comes to serving our patients.

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.

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

ID: 2020-3384

External Company Name: Commonwealth Care Alliance, Inc.

External Company URL:

Actual Work Location: CCC Clinic, Springfield, MA