Transitional Care Coord

Job Summary
SSHS is seeking an RN Care Manager to join the South Shore Health System Care Coordination team. As a member of a team of nurses, social workers, physicians, pharmacists, and program coordinators, you will have the opportunity to make a profound impact on the lives of people living with complex and/ or chronic conditions.  You will connect with your patients in person, on the phone, in the hospital, and in the physician’s office - essentially however and wherever the patient needs your assistance to improve their health, better understand their illness and coordinate their care. While the primary work setting is the physician’s office, must be prepared to work from home office, hospital or skilled nursing facility. Under the supervision of the Manager of Transitional Care, the RN Transitional Care Manager identifies, assesses, plans, coordinates and implements appropriate cost-effective healthcare services for individuals identified with special health care needs.  Special health care needs are defined as members who have or are at increased risk for chronic, physical, developmental, behavioral, or emotional conditions and who require health and related services of a type or amount beyond that required by members generally. The goal of the case manager is to provide an optimal outcome for the client though collaborating with the client, physician, family and other members of the health care team. 


  • This RN Care Manager  will connect with the patients in person, on the phone, embedded (on site) in the physician practice, hospital or Skilled Nursing Facility setting.   The RN CM will be providing face to-face interaction with patients and their care team when appropriate to improve patient care.
  • Along with other members of the Population Health team, conduct comprehensive assessments that include the medical, behavioral, pharmaceutical and social needs of the patient, identify gaps in care and barriers to attaining improved health.
  • Based on this assessment, and in conjunction with the patient, the patient’s physician and other members of the population health team, create and implement a care plan that will address the identified needs, remove the barriers and improve the health of the patient.
  • Coordinate care by serving as the contact point, advocate and resource for the patient, their family and their physician, building effective relationships through trust, respect and communication.
  • In close collaboration with the patient, primary care provider and care team you will continually assesses the patient’s knowledge of their clinical condition(s) and provide education and self-management support based on the patient’s unique learning style.
  • Measure, improve and maintain quality outcomes (clinical, financial, and functional) for individual patients and the population served.
  • Maintains a current knowledge base with regards to rules, regulations, policies, and procedures relating to Medical Management.  Regularly reviews and monitors compliance with the Health Plan’s policies and procedures.
  • Adheres to, state, and federal regulations.
  • Promptly makes recommendations to ensure compliance with rules, regulations, policies, and procedures.
  • Assists with developing and updating policies and procedures, as needed or requested.
  • Serves as a resource for internal and external customers regarding appropriate and alternative delivery settings, systems, and interventions.
  • Participates with outside agencies and community groups, as requested, with regards to program goals and improved member health outcomes.


  •  Bachelors Degree in Nursing
  • 3-5 years of nursing experience, preferably in home health, ambulatory care, community public health, case management, coordinating care across multiple settings and with multiple providers
  • Current MA Registered Nurse license
  • CCM or ACM or ability to sit for the exam, within 24 months of employment.
  • Unrestricted license to practice nursing in the state of  MA
Opportunity to work remotely, and may require travel to offsite locations for patient care visits.