Site: Mass General Brigham Community Physicians, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. The Opportunity Across the country, governments, employers, and American families have struggled in the face of rising healthcare costs. Efforts historically have targeted narrow programs and patient populations, and while many have succeeded, healthcare costs continue to rise. It’s time to take a radically different approach. A new approach involves putting the patient at the center with the goals of improving value and providing better outcomes at lower cost for patients. The Population Health Management (PHM) department at Mass General Brigham is charged with the challenge to drive better value for patients across Mass General Brigham. To achieve its goals, PHM leverages financial and clinical data to examine opportunities, designs and delivers innovative care models using product development and design thinking disciplines, and leverages problem solving, teamwork, and leadership skills to drive ongoing improvement. As an integral member of the Population Health Management Operations team, The Transition of Care Nurse Care Manager provides episodic care management for Medicare Shared Savings Program (MSSP) and Medicaid ACO patients from inpatient admission to home. This includes follow up phone calls after discharge, medication reconciliation, and ensuring patient has appropriate follow up appointments scheduled as well as documenting and ensuring all billing requirements are met prior to submitting TCM charges. The Transition of Care Nurse Manager directly interfaces with patients (via phone), Primary Care physicians, pharmacists, care managers, and health care teams involved in patient care as well collaborating with PHM Clinical Operations leadership. Job Summary Primary Responsibilities: 1. Manages episodic transitions of care for Medicare Risk and Medicaid risk patients from inpatient discharge to home as applicable. a. Calls all discharged patients within two business days of discharge and conducts post discharge assessments. b. Works alongside the PHM Clinical Pharmacist to identify and perform Medication Reconciliation for identified patients within the two day follow up phone call. c. Reviews discharge instructions/paperwork prior to call to review with patient any action items needed prior to follow up appointment. d. Facilitate face to face follow-up appointment with their PCP within 7-14 days after discharge (or according to discharge instructions if applicable). e. Document patient interaction (phone calls) in the appropriate patient chart in the electronic medical record. f. Manages and coordinates transitions of care by communicating the care plan to other providers and care managers and applicable practice staff. g. Maintains all documentation according to standards and requirements. h. Ensures all Transitions of Care (TCMs) meet appropriate billing requirements prior to submitting documentation to the billing department per protocol yet TBD. 2. Demonstrates effective teamwork and collaboration with the primary care provider and the care team a. Engages the patient and caregiver as active members of the care team and facilitates an organized and effective, warm hand off for transitions of care back to the patient's medical home (PCP). b. Participates in regular meetings with the providers and the care team to identify opportunities for better transitions or to modify workflows as needed. c. Communicates with other PHM and (Regional Service Operation (RSO) departments and sites to foster collaboration as a 'system' around the patients served. Organizational Responsibilities: 1. Demonstrates a positive attitude in dealing with patients, co-workers, and other health care providers and in addressing problems and/or crisis situations. 2. Requires the ability to work independently as well as function effectively within a team-based model of care. 3. Able to establish collegial relationships with physicians, office staff and health care providers in physician's offices, community agencies, hospitals, and other health care facilities. 4. Functioning within the patient centered model of care, demonstrates a commitment to meeting the patient’s needs and expectations. 5. Functioning within the team-based model of care 6. Demonstrates initiative and creativity to continuously improve services, work processes, and other activities that affect quality and utilization. 7. Follows applicable policies and procedures for general safety, fire safety, infection control, attendance, punctuality, and appearance. 8. Performs all duties as assigned. Other Duties and Responsibilities: 1. Assumes accountability for professional growth and development. 2. Acts as a role model for patients by practicing behaviors consistent with the program goals of health promotion and disease prevention. 3. Identifies quality of care issues and reports the concerns to the appropriate person. 4. Collects, prepares, and reports data as directed. 5. Assists in preparation for external audits and surveys as applicable. Qualifications Qualifications - Required: - Associate’s Degree Nursing (ASN) or Bachelor’s Degree Nursing (BSN). - RN License for State of MA. - 3+ years of experience in hospital, health plan or community case management or utilization management role. - Care management or home care background. - Managed Care or previous healthcare reimbursement knowledge. - Preferred: - Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. - Certification in Case Management (CCM) and/or other applicable professional certification preferred. - Previous experience working in a post-acute setting such as LTAC, acute rehabilitation, skilled nursing facility, or homecare. - Bedside nursing experience. Additional Skills, Knowledge and Abilities: - Excellent organizational skills. - Excellent oral, written, and telephonic skills and abilities. - Critical thinking and problem-solving ability. - Demonstrated ability to present and speak in front of groups. -Demonstrated competency working with health care setting computer systems. -Competence in Microsoft Word, Excel and PowerPoint. -Ability to work effectively with physicians and their staff in a physician practice setting. -Ability to work a flexible schedule including some required evenings or early mornings. -Knowledge of levels of care and the continuum of health care services. -Ability to handle routine work, unexpected priorities, and multi-task. -Requires autonomy in decision making using sound judgment based upon factual information, clinical experience and nursing process. -Ability to work with various practice sites. Additional Job Details (if applicable) Schedule and Work Model - Full-Time Monday through Friday, standard business hours (approximately 8:30am-5pm ET) - Remote with ability to travel to Assembly Row in Somerville, MA for team building, best practice sharing meetings and/or events. - As a remote employee, must use a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Department: 39744 Advocate Aurora Health Corporate - APP: Accountable Care Admin: Care Transition and Support Programs Status: Part time Benefits Eligible: Yes Hours Per Week: 20 Schedule Details/Additional Information: This is transitional care management position that supports patients discharged from the ED. This a fully remote position, high speed internet is required. Hours vary from 0800-2030 and will include holiday and every other weekend rotation IL RN license required. Pay Range $35.50 - $53.25 Part Time Care Transitions Nurse - This is a part-time remote role that requires high-speed internet and requires some evening and weekend coverage. Care Transitions role for both 30 and 90-day programs Medicare/ACO patient population/Medicare FFS program post-hospital discharge. Position Requirements: Bachelor`s Degree in Nursing. Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services. Excellent written and verbal communication skills. Strong organizational analytical and problem-solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team-based multidisciplinary environment. Registered Nurse license issued by the state in which the team member practices. May need to operate a motorized vehicle to facilitate home visits as appropriate. Must be able to sit stand and walk without restriction. Must have the ability to move about in confined spaces including bending twisting kneeling squatting and occasionally reaching one or both arms overhead. Must be able to concentrate on detailed information, tasks and functions for prolonged periods of time. Must be able to speak clearly and hear in order to communicate in-person or via telephone. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Purpose: Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Accountabilities: Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation - Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training - Premium pay such as shift, on call, and more based on a teammate's job - Incentive pay for select positions - Opportunity for annual increases based on performance Benefits and more - Paid Time Off programs - Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability - Flexible Spending Accounts for eligible health care and dependent care expenses - Family benefits such as adoption assistance and paid parental leave - Defined contribution retirement plans with employer match and other financial wellness programs - Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.

Department: 39744 Advocate Aurora Health Corporate - APP: Accountable Care Admin: Care Transition and Support Programs Status: Part time Benefits Eligible: Yes Hours Per Week: 28 Schedule Details/Additional Information: This is a transitional care management position that supports patients discharged from the ED. This a fully remote position, high speed internet is required. Hours vary from 0800-2030 and will include holiday and every other weekend rotation IL RN license required. Pay Range $35.50 - $53.25 Part Time Care Transitions Nurse - This is a part-time remote role that requires high-speed internet and requires some evening and weekend coverage. Care Transitions role for both 30 and 90-day programs Medicare/ACO patient population/Medicare FFS program post-hospital discharge. Position Requirements: Bachelor`s Degree in Nursing. Typically requires 2 years of experience in nursing in an acute care or community setting with an emphasis in palliative care or senior services. Excellent written and verbal communication skills. Strong organizational analytical and problem-solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team-based multidisciplinary environment. Registered Nurse license issued by the state in which the team member practices. May need to operate a motorized vehicle to facilitate home visits as appropriate. Must be able to sit stand and walk without restriction. Must have the ability to move about in confined spaces including bending twisting kneeling squatting and occasionally reaching one or both arms overhead. Must be able to concentrate on detailed information, tasks and functions for prolonged periods of time. Must be able to speak clearly and hear in order to communicate in-person or via telephone. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Purpose: Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Accountabilities: Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation - Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training - Premium pay such as shift, on call, and more based on a teammate's job - Incentive pay for select positions - Opportunity for annual increases based on performance Benefits and more - Paid Time Off programs - Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability - Flexible Spending Accounts for eligible health care and dependent care expenses - Family benefits such as adoption assistance and paid parental leave - Defined contribution retirement plans with employer match and other financial wellness programs - Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.

Cardinal Health Sonexus™ Access and Patient Support helps specialty pharmaceutical manufacturers remove barriers to care so that patients can access, afford and remain on the therapy they need for a better quality of life. Our diverse expertise in pharma, payer and hub services allows us to deliver best-in-class solutions—driving brand and patient markers of success. We’re continuously integrating advanced and emerging technologies to streamline patient onboarding, qualification and adherence. Our non-commercial specialty pharmacy is centralized at our custom-designed facility outside of Dallas, Texas, empowering manufacturers to rethink the reach and impact of their products. What Individualized Care contributes to Cardinal Health Delivering an exclusive model that fully integrates direct drug distribution to site-of-care with non-commercial pharmacy services, patient access support, and financial programs, Sonexus Health, a subsidiary of Cardinal Health, helps specialty pharmaceutical manufacturers have a greater connection to the customer experience and better control of product success. Personalized service and creative solutions executed through a flexible technology platform means providers are more confident in prescribing drugs, patients can more quickly obtain and complete therapy, and manufacturers can directly access more actionable insight than ever before. With all services centralized in our custom-designed facility outside of Dallas, Texas, Sonexus Health helps manufacturers rethink how far their products can go. Responsibilities The Case Manager supports patient access to therapy through Reimbursement Support Services in accordance with the program business rules and HIPAA regulations. This position is responsible for guiding the patient through the various process steps of their patient journey to therapy. These steps include patient referral intake, investigating all patient health insurance benefits (pharmacy and medical benefits), and proactively following up with various partners including the insurance payers, specialty pharmacies, support organizations, and the patient/physician to facilitate coverage and delivery of product in a timely manner. - Investigate and resolve patient/physician inquiries and concerns in a timely manner - Mediate effective resolution for complex payer/pharmacy issues toward a positive outcome to de-escalate - Proactive follow-up with various contacts to ensure patient access to therapy - Demonstrate superior customer support talents - Prioritize multiple, concurrent assignments and work with a sense of urgency - Must communicate clearly and effectively in both a written and verbal format - Must demonstrate a superior willingness to help external and internal customers - Working alongside teammates to best support the needs of the patient population or will transfer caller to appropriate team member (when applicable) - Maintain accurate and detailed notations for every interaction using the appropriate database for the inquiry - Must self-audit intake activities to ensure accuracy and efficiency for the program - Make outbound calls to patient and/or provider to discuss any missing information as applicable - Assess patient’s financial ability to afford therapy and provide hand on guidance to appropriate financial assistance - Documentation must be clear and accurate and stored in the appropriate sections of the database - Must track any payer/plan issues and report any changes, updates, or trends to management - Handle escalations and ensure proper communication of the resolution within required timeframe agreed upon by the client - Ability to effectively mediate situations in which parties are in disagreement to facilitate a positive outcome - Concurrently handle multiple outstanding issues and ensure all items are resolved in a timely manner to the satisfaction of all parties - Support team with call overflow and intake when needed - Proactively following up with various partners including the insurance payers, specialty pharmacies, support organizations, and the patient/physician to facilitate coverage and delivery of product in a timely manner. Qualifications - 3-6 years of experience preferred - High School Diploma, GED or technical certification in related field or equivalent experience, preferred What is expected of you and others at this level - Effectively applies knowledge of job and company policies and procedures to complete a variety of assignments - In-depth knowledge in technical or specialty area - Applies advanced skills to resolve complex problems independently - May modify process to resolve situations - Works independently within established procedures; may receive general guidance on new assignments - May provide general guidance or technical assistance to less experienced team members TRAINING AND WORK SCHEDULES: Your new hire training will take place 8:00am-5:00pm CT, mandatory attendance is required. This position is full-time (40 hours/week). Employees are required to have flexibility to work any of our shift schedules during our normal business hours of Monday-Friday, 7:00am- 7:00pm CT. REMOTE DETAILS: You will work remotely, full-time. It will require a dedicated, quiet, private, distraction free environment with access to high-speed internet. We will provide you with the computer, technology and equipment needed to successfully perform your job. You will be responsible for providing high-speed internet. Internet requirements include the following: Maintain a secure, high-speed, broadband internet connection (DSL, Cable, or Fiber) at the remote location. Dial-up, satellite, WIFI, Cellular connections are NOT acceptable. Download speed of 15Mbps (megabyte per second) - Upload speed of 5Mbps (megabyte per second) - Ping Rate Maximum of 30ms (milliseconds) - Hardwired to the router - Surge protector with Network Line Protection for CAH issued equipment Anticipated hourly range: $21.40 per hour - $30.60 per hour Bonus eligible: No Benefits: Cardinal Health offers a wide variety of benefits and programs to support health and well-being. - Medical, dental and vision coverage - Paid time off plan - Health savings account (HSA) - 401k savings plan - Access to wages before pay day with myFlexPay - Flexible spending accounts (FSAs) - Short- and long-term disability coverage - Work-Life resources - Paid parental leave - Healthy lifestyle programs Application window anticipated to close: 5/11/2026 *if interested in opportunity, please submit application as soon as possible. The hourly range listed is an estimate. Pay at Cardinal Health is determined by multiple factors including, but not limited to, a candidate’s geographical location, relevant education, experience and skills and an evaluation of internal pay equity. Candidates who are back-to-work, people with disabilities, without a college degree, and Veterans are encouraged to apply. Cardinal Health supports an inclusive workplace that values diversity of thought, experience and background. We celebrate the power of our differences to create better solutions for our customers by ensuring employees can be their authentic selves each day. Cardinal Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, ancestry, age, physical or mental disability, sex, sexual orientation, gender identity/expression, pregnancy, veteran status, marital status, creed, status with regard to public assistance, genetic status or any other status protected by federal, state or local law. To read and review this privacy notice click here