Established in 1980, the Greater Lawrence Family Health Center (GLFHC) is a multi-site mission-driven non-profit organization employing over 700 staff whose primary focus is providing the highest quality patient care to residents throughout the Merrimack Valley. Nationally recognized as a leader in community medicine (family practice, pediatrics, internal medicine, and geriatrics), GLFHC has clinical sites throughout the service area and is the sponsoring organization for the Lawrence Family Medicine Residency program.
GLFHC is currently seeking a Transition of Care Coordinator Nurse (TOC Coordinator Nurse) to join our care management team. The Transition of Care Coordinator Nurse (TOC Coordinator Nurse) supports the Integrated Care (ICT) and Care Management teams in managing care transitions for GLFHC patients discharged from facilities and or treated and discharged from the Emergency Department (ED). The Transition of Care program is under the leadership of the Director of Population Health who is responsible for ensuring patient's care transitions needs are addressed timely and efficiently and their risk for readmission or E.D. recidivism is minimized. Within this context, the TOC Coordinator Nurse communicates with members of the ICT and care management teams as needed and escalates patient needs based on protocols. In addition to managing key administrative duties related to data review, (admission, discharge and transfer reports and identifying any patients for whom their TOC will be coordinated by the Community Partner, the TOC Coordinator Nurse will proactively outreach patients and conduct post discharge interviews to assess their post discharge needs, identify gaps and implements intervention based on protocols. Guided by evidence based clinical and social care management guidelines, the coordinator will ensure all follow-up appointments are in place and health related social barriers are identified and addressed. The TOC Coordinator Nurse refers to care management based on established criteria. The Transitions of Care Nurse, adheres to program guidelines in accordance with regulatory requirements outlined in the MassHealth ACO contract.

• Provide follow up calls as needed up to 30 days after discharge to insure follow up appointments and the need for community support services are in place.
• Assist patient in making follow up appointments with PCP and escalate to the primary care clinician and site operations leader any scheduling barriers that impact timely access.
• Assist patients with health related social needs that are barriers to successful care transitions, such as financial, transportation, food, housing, Medicaid application etc.
• Identify and escalate any risk factors during patient outreach and communicate with the ICT Nurse or Care Manager assigned. Educate patients when appropriate regarding utilizing urgent care or E.D.
• Provide patients with information on GLFHC and Community Practice clinic hours, average wait times, and guidance on when to seek primary, urgent and emergent care.
• Actively participate in discharge education and planning.
• Documents all patient interview responses and teaching material given to the patients, or family members including their response, comprehension and need for further follow-up.
• Support clinical programs under the direction of, community support services to ensure appropriate transitions of care take place while enrolling patients with services at GLFHC.
• Attend appropriate staff and community meetings. Participate in community education and health promotion programs when requested.

Under the direction of the Population Health Director, obtain and maintain statistical data to demonstrate clinical encounters.
Qualifications:
Education:

• Current Massachusetts Nursing License from an accredited program; RN preferred.
• Current BLS Certification.
• Bilingual (English/Spanish) required. Must be fluent in both spoken and written English and Spanish.

Experience:

• Minimum of 3 years of healthcare/community services experience in related /similar role or (if applicable) as a practicing nurse.
• Experience in community-based program, including transition of care experience highly desired. Service delivery preferred.
• Computer knowledge required, including documenting in an EMR.
• Excellent communication skills required.
• Computer proficiency, especially in Microsoft Word, Excel and Outlook. Must complete EMR training after hire.
• Valid Massachusetts Driver's license and access to reliable transportation.
• Ability to work flexible hours for coverage depending on needs of the patients and organization.
• Must be organized and able to multi-task in a fast paced environment.
• Must demonstrate ability to think critically and escalate if indicated.

Must demonstrate ability to interview and interact with patients so that the collection of assessment data is optimized and the patient is motivated to engage.
GLFHC offers a great working environment, comprehensive benefit package, growth opportunities and tuition reimbursement.