Trinity Health Discharge/Follow up Care Coordinator in Springfield, Massachusetts

40 hour, 5 days a week position flexing between the hours of 7a-7p This position will be responsible for coordinating follow up and care coordination for Emergency Department patients who require further interventions. The Discharge Follow-Up Coordinator directly interfaces with physicians, health care teams, patients and their caregivers as needed in managing patient care. Manages identified populations with minimal direction from management. Ensures the attainment of departmental goals and objectives.


Reviews all final microbiological reports for the Emergency Department and reviews chart to ensure proper treatment and follow up, if necessary.

Identifies potential barriers to patient compliance with treatment plan.

Reviews finalized Emergency Department Radiology Reports for potential change in discharge plan of care.

Works directly with physician lead to review diagnostic studies, clinical history and course of treatment to identify most appropriate next course of care.

Assists patient in navigating appropriate specialist follow-up as needed.

Provides follow-up phone calls to predetermined subset of the Emergency Department population in an effort to advocate for and assist the patient in the achievement of optimal health.

Works in conjunction with the Complex Care Coordinator to audit compliance with care map recommendations.

Works cooperatively with appropriate department managers/supervisors and Complex Care Coordinator to assist in developing corrective action plans to improve outcomes. Acts as a consultant/clinical resource person to support staff in monitoring compliance with complex care plans.

Recommends corrective action for all staff that is not compliant and/or adhering to the patients' individualized Complex Care Plan and Mercy Medical Center Policies and Procedures.

Expertly uses verbal and non-verbal communication skills of motivation, explanation and reassurance to gain cooperation of patients and care providers in the use of their treatment plans.

Uses critical thinking and problem solving skills to analyze and synthesize data and formulate an appropriate plan to address the patient’s individual and family needs.

Assures appropriate sequencing of care/interventions for optimal results and smooth transitions throughout the continuum of care.

Acts as a member of the Complex Care team and serves as a resource for management of specific patient populations.

Serves as a navigator and facilitator between patients, other healthcare providers, and third party payers to establish a supportive environment for patients.

Creatively utilizes multiple resources to engage challenging patient populations up to and including potential community outreach.


Requires current unrestricted Commonwealth of Massachusetts RN licensure. Three to five (3 to 5) years demonstrated clinical experience. Two (2) years of case management experience preferred.

Knowledge of nursing practices acquired by completing a Bachelor’s of Science in Nursing required.

Ability to comfortably and effectively interact with diverse populations.

Ability to impact patient outcomes through change management and influence.

CPR certification required.

Bilingual (Spanish/English) preferred.



A few unpleasant conditions routinely present (cramped working space, drafty area, poor lighting, inadequate equipment or refurnishings); or occasional exposure to occupational hazards or contagious disease, which requires routine precautions.

Work demands and irregularity of hours create considerable inconvenience for home and social life planning, such as frequent availability, or constant shift rotation, or location imposes frequent interruptions and distractions that are bothersome and not inherent in the work. Work requires frequent substantive involvement in stressful situations causing considerable strain routinely.

Requires prolonged standing, walking, or other constant physical movements on a routine basis; or requires remaining in same position over long periods of time; or eye or ear strain.

Will require flexibility in hours to serve the needs of the department as necessary.



Reports to the Director of Emergency Services.

Not responsible for the direct supervision of any staff.


Job Number: 00112524

Location: Springfield, MA

Organization Name: Mercy Medical Center

Facility: SPMA - Mercy Medical Center

Employment Type: Full time

Shift: Day Shift

Hours: 40