Continuity Nurse- RN

Continuity Nurse- RNSalary Range: $37.00-40.00/Hour Final Salary determined on experience, licensure, etc. Are you looking for a meaningful career? Are you passionate about healthcare in your community? Do you enjoy helping people?Edward M. Kennedy Community Health Center is one of the largest community health centers in Massachusetts serving Worcester, Framingham, Milford and the surrounding communities. We are a thriving and growing organization, and our team is expanding across sites to support this growth.We are currently hiring a Continuity Nurse- RN, based in Worcester, MA. 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. Essential FunctionsReviews 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.Education and ExperienceCurrent Massachusetts Registered Nurse (RN) LicenseCurrent Basic Life Support (BLS) certification2 years of external experience, 1.5 years of experience at Kennedy Community HealthDemonstrated experience and/or interest in working with transgender individuals.Benefits:Competitive salary based on related experienceMedical insurance starts on the first day of employment. Includes coverage for all individuals and most family types.Generous time off packagesDental and Vision insurance403b Retirement Plan with employer matchFlexible Spending AccountsEmployee Assistance Program