Continuity Nurse- RN
About The Position
The Continuity Nurse supports care coordination for patients following emergency room visits and hospital admissions. This role is responsible for identifying, triaging, tracking, and scheduling patients to help ensure timely follow-up and continuity of care. The Continuity Nurse will also work closely with the Quality Improvement RN to identify and track patients with outstanding preventive care needs and help connect them with appropriate services. As an employer of choice, our inclusive workplace environment fosters teamwork, accountability and respect and supports the growth and development of each employee. We are an equal opportunity employer and embrace the richness of the cultures of our staff and community. You are a good fit for our team if you’re passionate about helping people live healthier lives and enjoy working in a supportive, team-based environment.
Requirements
- Current Massachusetts Registered Nurse (RN) License
- Associate’s or Bachelor of Science in Nursing (BSN) degree from an accredited college or university
- Current Basic Life Support (BLS) certification
Responsibilities
- Reviews admission, discharge, and transition reports and patient records to determine appropriate services based on patient needs.
- Develops relationships with participating hospitals and community partner organizations.
- Contacts patients within 24–72 hours of an ED visit or hospital discharge to assess follow-up needs and coordinate services using the EHR.
- Conducts telehealth visits, when appropriate, to provide education and develop post-hospital/ED care plans.
- Collaborates with Primary Care Teams to coordinate appointments, services, and address barriers to care.
- Helps patients navigate the healthcare system by providing guidance on processes, resources, and available services.
- Performs utilization reviews and identifies high-cost/high-utilization cases, recommending opportunities to improve care and reduce costs.
- Reviews preventive care gap reports and conducts outreach to high-risk patients.
- Participates in performance improvement initiatives and quality improvement processes.
Benefits
- Competitive salary based on related experience
- Medical insurance starts on the first day of employment.
- Health center pays 80% of medical insurance premiums.
- Includes coverage for all individuals and most family types.
- Generous time off packages
- Dental and Vision insurance
- 403b Retirement Plan with employer match
- Flexible Spending Accounts
- Employee Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
