Job Description


Under general direction, oversees, monitors, coordinates, and supervises the daily operations of Steward Health Care Network's Transitions team. Works collaboratively with the care management team and other internal and external stakeholders to ensure an excellent level of service and clinical care.


• Responsible for the direct supervision of the transitions team including clinical and non-clinical staff.
• Provides clinical oversight and supervision to non-registered nurse staff.
• Works in conjunction with the Manager of Care Management on training and team development.
• Designs transition of care plans with the patient. Collaborates with the patient/family, hospital team, primary care team, specialists, SCHN Medical Director, Extended Care Case Managers, Social Workers, Wellness Coordinators and other Steward Health Care Network programs, community services, and other members of the health care team to ensure safe transitions of care, effective coordination of services, and full understanding and execution of the care plan.
• Actively reviews available reports, considers care management (CM) impact; recommends and makes modifications to the plan of care, as needed.
• Maintains required medical documentation for case management activities in the system's care management module (electronic medical records), according to the standards of work.
• Meets regularly with each direct report individually to review cases and provide coaching and mentoring; conducts regular staff meetings.
• Identifies staffing needs to support the organization and develops staffing strategies to ensure appropriate coverage to meet daily and unexpected requirements.
• Follows standards of work and consistently maintains department established caseloads and timeframes for case completion. Participates in the refinement of and development of new standards of work.
• Responsible for implementation, monitoring and adherence of time off policies and procedures.
• Identifies on-going educational needs and opportunities for staff based on the requirements of the position and specific needs of the individual.
• Develops plans for corrective action in areas identified for improvement
• Evaluates processes, identifies problems, and proposes improvement strategies to enhance the delivery of care for patients throughout continuum of care. Maintains awareness of key performance indicators/metrics and manages caseload through appropriate management of medical expenses. Coordinates interventions to prevent adverse events such as ED visits, hospital admissions and readmissions.
• Meets regularly 1-1 with the Manager of Care Management to review caseload and discuss barriers/challenges and review performance compared to current targets/expectations.
• Demonstrates leadership that creates and fosters a culture of continuous improvement in the department
• Documents and reports all quality and patient safety events by recording and adhering to all of Steward Health Care Network's safety reporting guidelines.
• Performs all job functions in compliance with applicable federal, state, local, and company policies and procedures.
• Performs other duties as assigned


• Must exhibit excellent critical thinking skills, problem solving, interpersonal, and good patient interviewing skills.
• Highly motivated and self-directed.
• Ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care.
• Ability to lead and motivate others to execute a plan in a rapidly changing environment.
• Demonstrated ability to prioritize, multitask, and work in a rapidly changing environment with multiple demands.
• Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve outcomes.
• Strong current working knowledge of care management and health care across the continuum.
• Ability to utilize tools for the effective documentation of the care management process.
• Ability to work effectively in a team.
• Ability to travel to attend chapter POD meetings as necessary and to visit select practice sites for meetings with patients, PCPs and other members of the care team.
• Attend staff meetings and education offerings both in person and via teleconference as required.


• Graduate of a state-approved school of nursing, BSN preferred.
• Possess a current unrestricted RN licensure in the Commonwealth of Massachusetts.
• Must maintain Basic Cardiac Life Support (BCLS) certification.
• Certified Case Management (CCjaM) or CCM eligible strongly preferred.

• Minimum of 3-5 years' relevant clinical nursing experience required, 1-2 years of experience in Care Management/Management role strongly preferred.

Application Instructions

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