New

Transitional Care RN, Primary Care

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Boston
Feb 02, 2026
We are seeking a 36-hour Transitional Care Nurse Case Manager to join our fully remote team, working Monday through Friday, 8:00 AM - 4:30 PM. In this role, you will spend your day on the phone, reaching out to patients discharged from hospitals, rehabs, and emergency rooms, collecting medical history, performing clinical screenings, and ensuring they are connected with their primary care providers. Calls are often 45 minutes or longer and require detailed documentation in Epic. The ideal candidate will have at least an Associate's degree in Nursing, with a primary care or hospital nursing background, be comfortable working autonomously, and be highly organized and skilled at phone-based clinical care. Epic experience is a plus. Serves as a core member of the care team coordinates and supports healthcare within the facility, and coordinates referrals for services outside the clinic. Provides outreach and enrollment services to meet eligibility requirements of the program and surrounding counties. Ensures coordination and planning, including community and family support. Focuses on the development and coordination of community service plans. Partners with service providers, families, and patients to create a plan of healthcare and identify additional service providers. Does this position require Patient Care? Yes Essential Functions -Client Assessments and Planning -Modify patient treatment plans as indicated by patients' responses and conditions. -Prepare patient/family for discharge -Communicates with third party payers to obtain necessary authorization for reimbursement of services. -Review cases with medical directors on challenging cases as needed -Defines care goals of patients by providing education, information, and direction to each individual and family. -Maintain accurate, detailed reports and records. -Communicates with third party payers to obtain necessary authorization for reimbursement of services. Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials Registered Nurse [RN - State License] required Basic Life Support [BLS Certification] preferred Experience Case management, utilization review, or discharge planning experience 2-3 years preferred Knowledge, Skills and Abilities - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. - Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. - Ability to establish strong rapport and relationships with patients and staff. - Proficient in Microsoft Office and industry related software programs. - Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. - Ability to maintain client and staff confidentiality. - Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. - Knowledge of Healthcare and Managed Care preferred. Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.