At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.
At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.
Job Summary
The inpatient Complex Care Team Nurse is responsible for assisting the Complex Care Team (CCT) in executing the strategic vision of CCM related to the discharge management of high-risk patients across the continuum and the Brigham Health post-acute strategy. Care Continuum management is a multi-disciplinary pursuit whose mission is to ensure that all patients receive high quality and safe care that is seamless and coordinated across different locations and occurs in the most appropriate care setting for a given patient and/or population. The Complex Care Team Nurse (and other CCT members) as well as Complex Care Management, involves supporting barriers to discharge for patients who require additional coordination of care due to their clinical complexity, psychosocial needs, or financial vulnerability. The Complex Care Team Nurse, along with the post-acute strategy and CCT team and primary care teams, ensure that the Brigham Health patients who require any type of post-acute care are appropriately identified and can access the highest quality post-acute care at discharge, seamlessly, timely and safely.
Qualifications
Can this role accept experience in lieu of a degree? Yes
Licenses and Credentials:
License/Certification:
RN
Timeframe: Upon Hire
☒ Required or ☐ Preferred
License/Certification:
CCM
Timeframe: Upon Hire
☐ Required or ☒ Preferred
License/Certification:
ACME
Timeframe: Upon Hire
☐ Required or ☒ Preferred
Education:
Degree: Bachelor's Degree
Field of Study: Nursing
☐ Required or ☒ Preferred
Degree: Master's Degree
Field of Study: Nursing / Public Health
☐ Required or ☒ Preferred
Additional Job Details (if applicable)
1. Pro-actively reviews patients needing post-acute services, home health, skilled nursing care, acute rehab, LTAC for barriers to discharge.
2. Ensures quality metrics such as length of stay are evaluated on a routine basis.
3. Responds to consults, pages, phone calls, emails and Voalte messages/escalations from CCM members, providers, internal departments, external sources and others.
4. Attends and actively participates in required meetings related to the Complex Care Team work @BWH & BWFH, including but not limited to the clinical care teams meeting and/or huddles, patient and family team meetings, provider meetings, or external collaborator meetings.
5. Utilizes EPIC and 4Next to review clinical details and track patient progression.
6. Serves in a consulting role for RN Care Coordinators, offering support and guidance for patients with complex discharge needs. Facilitates coordination of care for CCT patients to home with services, hospice, skilled nursing facilities, shelters, State Hospitals, Acute Rehab or LTACH’s in collaboration with the RN Care Coordinator and multidisciplinary teams.
7. Acts as an advocate for the Complex Care Patient while helping to navigate any barriers to care and progression to discharge. This includes communications with payers for authorization needs and collaboration for coverage on discharge.
8. Effectively communicates with RN Care Coordinators, multidisciplinary teams and / or other health care professionals to alert providers and team about potential issues and solution to barriers. Able to effectively document in EMR regarding case updates and messages necessary providers for follow up.
9. Maintains excellent relationships within the Brigham family and with leaders of post-acute care organizations both within and external to MGB Healthcare.
Remote Type
Hybrid
Work Location
45 Francis Street
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
EEO Statement:
The Brigham and Women's Hospital, Inc. is an Affirmative Action 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.
Mass General Brigham Competency Framework
At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.