Skilled Nursing Transitions Coordinator
2 months ago
Harbor Health Services operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. We are looking for an talented Skilled NursingTransitions Coordinator to join our team at the Elder Service Plan in Brockton.
Harbor Health offers an excellent, comprehensive benefits package including Health, Dental, Vision, Life, & Disability insurance, 403b Savings Plan, Generous Paid Time Off (20 days to start) plus 11 additional Holidays and much more
Role:
Under the general direction of the Director of Care Coordination, the Skilled Nursing Transitions Coordinator partners with the Interdisciplinary Team (IDT) to facilitate the progression of care for Harbor PACE Elder Service Plan (ESP) participants in short term rehabilitative, skilled nursing, and long-term acute care facilities. Using a collaborative approach, the Interdisciplinary Team focuses on delivery of efficient, high quality rehabilitative and skilled nursing care. The Care Transitions Case Manager ensures appropriate utilization of skilled nursing resources with a goal of safe and timely discharge for the Harbor ESP participants and navigates and utilizes ESP services to support effective transitions. Our ideal candidate must be adept at utilization review, care coordination, discharge planning, fiscal responsibility, and relationship development.
Responsibilities:
Works in close collaboration with other members of the Interdisciplinary and Utilization Management team around all Subacute, Skilled Nursing Facility (SNF), and Long Term Acute Care (LTAC) transitions.
Serves as a collaborative bridge between ESP and SNFs.
Performs prospective, concurrent, and retrospective utilization management-related reviews and ensures all data are tracked, evaluated, and reported.
Utilizes clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
Collaborates with ESP interdisciplinary teams and subacute/skilled nursing facilities regarding management of members not meeting continuing stay criteria.
Obtains and communicates clinical information effectively to participant, family/caregiver, Interdisciplinary Team and SNF/Subacute facility.
Works collaboratively with Utilization Management Nurses and Care Coordinators to ensure facilities have all information and paperwork needed to care for the participant at the time of admission.
Authorizes length of stay appropriate for condition and level of function and communicates to appropriate facility.
Actively seeks clinical documentation and reviews all assessments and clinical information for every active SNF/Subacute/LTAC stay and ensures ESP has comprehensive Electronic Health Record (EHR) records.
Supports different disciplines in overcoming barriers to discharge, including housing, functional needs, and caregiver support.
Serves as conduit for family and home facility (e.g., ALF) communication for discharge planning.
Develops trusted relationships with SNFs, including attending meetings and routine site visits to contracted facilities.
Maintains tight control of active SNF/LTAC caseload, knows goals to discharge, barriers, etc., escalates issues on team meetings, follows action items to completion and supports IDT members needing access to SNF information.
Facilitates All-Teams SNF weekly utilization review meetings with IDT including prepares and maintains meeting spreadsheets for effective meeting management, ensures action items are addressed, communicates planned discharge dates, sends updated authorizations and additional pertinent information as needed to respective SNF/Subacute facilities.
Responsible for reviewing, close monitoring and authorizations for add-on charges for participants in long term care when appropriate.
Responsible for obtaining the information necessary to assess a participant’s clinical condition, identifies ongoing clinical care needs and ensures that participants receive services in the most optimal setting to effectively meet their needs.
Ensures all services needed for safe discharge are in place including Home Health Aides/Caregivers, nursing, Durable Medical Equipment (DME), rehab, transportation, family, etc., ensures Discharge Summary with medication list is obtained and as appropriate, completes assessment tools and enters orders (e.g., DME, home health aides, etc.).
Triggers Change of Status actions when participants are unable to return home.
Conducts regular and as-needed in-person visits to contracted Skilled Nursing Facilities for relationship-building, resident visits, quality checking, etc.
Uses Patient Ping to track participant disposition.
Requirements:
Associate in nursing (ADN) required, BSN preferred or degree in other discipline as indicated by licensure (see substitutions)
Current, valid, and unrestricted Registered Nurse (R.N.) license or other valid MA license as indicated in substitutions
Substitutions for RN license: LPN (Licensed Practical Nurse) with 4 additional years of Skilled Nursing Facility experience
Registered Physical or Occupational Therapist (PT/OT)
OTA/PTA with 4 additional years of Skilled Nursing Facility experience.
Current BLS (Basic Life Support for Health Care Providers) Certification
Current, valid, and unrestricted MA Registered Nurse (R.N.) license.
2 years of experience in a Skilled Nursing Facility as Staff Nurse, Nurse Case Manager, Nurse discharge planner or clinical manager
2 years of experience working in geriatric care
Experience with hospital discharge and/or home care experience preferred
Proficient in Microsoft Office 365 skills to include in Word, Excel, Outlook and Teams, database use, Nursing Home Electronic Health Records, and data entry
Demonstrated ability to run effective meetings – both virtual and in-person.
Must be able to travel between two or more sites and to outside contract agencies in a timely manner.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
-
Skilled Nursing Transitions Coordinator
2 months ago
Brockton, United States Harbor Health Services Full timeHarbor Health Services operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participants. We are looking for an talented Skilled...
-
Brockton, United States Harbor Health ESP Full timeSign on bonus of $5000. offered.* Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health,...
-
Skilled Nursing Transitions Nurse Coordinator
3 weeks ago
Brockton, United States Harbor Health ESP Full timeSign on bonus of $5000. offered.* Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health,...
-
Brockton, United States Harbor Health Services Full timeSign on bonus of $5000. offered.* The following information aims to provide potential candidates with a better understanding of the requirements for this role. Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan...
-
Brockton, United States Harbor Health Services, Inc. Full timeSign on bonus of $5000. offered.* Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in Mattapan and Brockton, MA and cares for more than 580 participant of the programs. We are...
-
Skilled Nursing Transitions Nurse Coordinator
12 hours ago
Brockton, United States Harbor Health Services, Inc. Full timeSign on bonus of $5000. offered.*The following information aims to provide potential candidates with a better understanding of the requirements for this role.Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has...
-
Brockton, MA, United States Harbor Health Services, Inc. Full timeSign on bonus of $5000. offered.* The following information aims to provide potential candidates with a better understanding of the requirements for this role. Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan...
-
Brockton, Massachusetts, United States Harbor Health ESP Full timeJob SummaryWe are seeking a skilled and compassionate Geriatric Care Coordinator to join our team at Harbor Health ESP. This is an exciting opportunity to work with a dynamic organization that prioritizes providing high-quality care to seniors in need of skilled nursing services.
-
Brockton, United States Harbor Health Services Full timeSign on bonus of $5000. offered.* Harbor Health operates two Elder Service Plan Programs of All-Inclusive Care for the Elderly (PACE), a program that allows frail elders to live in their homes and communities. Our Elder Service Plan has two medical and day centers in....
-
Nurse Coordinator, Virtual Care
3 weeks ago
Brockton, United States Harbor Health ESP Full timeSign on bonus of $5000. Harbor Health Services is an innovative, growing, mission-based organization that lives, serves and collaborates with our community members to achieve our mission to help individuals reach their full potential through access to local, affordable services that promote health. Harbor provides medical, behavioral health, dental, and...
-
Clinical Transition Team
2 months ago
Brockton, United States Old Colony YMCA Full timeOld Colony Y. Urgently seeks to hire a Clinical Transition Team (CTT) Clinician who will reports to Community Clinical Coordinator. The CTT Clinician's role is to provide clinical interventions and support to youth and families as youth transition from residential placement to the community. The Clinician's role is a time-limited clinical intervention...
-
Nurse Care Coordinator
6 days ago
Brockton, Massachusetts, United States Steward Health Care Full timeSteward Health Care seeks a skilled Registered Nurse to join our team as a Nurse Care Coordinator. As a valued member of our healthcare organization, you will play a critical role in providing high-quality patient care and ensuring seamless transitions between healthcare services.About the Role:Assess patient needs and develop individualized care plans to...
-
Emergency Department Nurse
14 hours ago
Brockton, Massachusetts, United States Boston Medical Center (BMC) Full timeAbout Boston Medical CenterBoston Medical Center (BMC) is a leading academic medical center with a long history of providing exceptional, personalized health care to the communities we serve.Job SummaryWe are seeking an experienced Emergency Department Registered Nurse who will provide high-quality patient care and coordinate efforts to ensure optimal...
-
Brockton, Massachusetts, United States Informatix Health, Inc. Full timeWe are seeking a dedicated Nursing Professional to join our team at Informatix Health, Inc. in various skilled care settings.Company OverviewInformatix Health, Inc. is a healthcare staffing agency that contracts with health facilities to provide temporary staffing solutions. Our mission is to meet the needs of our clients while providing a caring and...
-
Nursing Professional for Skilled Care
6 days ago
Brockton, Massachusetts, United States Informatix Health, Inc. Full timeInformatix Health, Inc. is a healthcare staffing agency that partners with health facilities to provide temporary staffing solutions. Our mission is to meet the needs of our clients and deliver superior staffing services in a caring and compassionate environment.We are seeking a skilled nursing professional to join our team at one of our skilled nursing...
-
Senior Skilled Nurse Professional
6 days ago
Brockton, Massachusetts, United States Aveanna Healthcare Full timeJob DescriptionAveanna Healthcare is seeking a skilled Registered Nurse (RN) to provide high-quality patient care in the comfort of their own homes. As a Senior Skilled Nurse Professional, you will work closely with patients and their families to develop personalized care plans that meet their unique needs.About the Role:Deliver and coordinate quality...
-
ICU Nurse Specialist
4 weeks ago
Brockton, Massachusetts, United States Steward Health Care Full timeAbout the Role:We are seeking a highly skilled and dedicated ICU Nurse Specialist to join our team at Good Samaritan Medical Center. The successful candidate will be responsible for providing high-quality nursing care to critically ill patients and their families, while also collaborating with multidisciplinary teams to ensure seamless care...
-
Nursing Care Professional
1 week ago
Brockton, Massachusetts, United States Aveanna Healthcare Full timeJob Overview:Aveanna Healthcare seeks a dedicated and compassionate Registered Nurse (RN) to provide high-quality skilled nursing care in the comfort of patients' homes. As a key member of our team, you will be responsible for delivering personalized patient care, ensuring compliance with physician orders, and maintaining accurate records.About the Role:-...
-
Brockton, Massachusetts, United States LRS Healthcare - Travel Nursing Full timeTravel Nursing Opportunity in MassachusettsLRS Healthcare - Travel Nursing is seeking a skilled travel nurse for a 12-week assignment in Plymouth, Massachusetts.About the JobJob Type: Travel NursingSpecialty: Operating RoomShift: 8 hours, daysThis is an excellent opportunity to work with a top healthcare facility and enjoy a competitive compensation...
-
Brockton, Massachusetts, United States PHP Full timeWe are seeking a highly skilled travel nurse RN to join our dynamic healthcare environment. This exciting opportunity is perfect for a dedicated and compassionate individual who wants to make a meaningful difference in the lives of patients.About the RoleThis 13-week contract will have you working in Med Surg / Telemetry, providing top-notch care to patients...
