Care Transitions RN Case Manager 24 Hours Days

Beth Israel Lahey Health; Boston (MA); On-site; USD 54,000 - 139,000; Full time

Job summary

Beth Israel Lahey Health is seeking an RN Case Manager in the Triad Model of Care Transitions to partner with the interdisciplinary care team and support safe, timely discharge for hospitalized patients. You will review admissions within 24–48 hours, coordinate with physicians and social workers, and ensure appropriate utilization of resources to facilitate transitions.

The role emphasizes communication, adherence to regulatory guidelines, and ongoing collaboration to improve patient flow,

Qualifications

• RN licensure in the state of Massachusetts.
• Bachelor's degree in nursing or healthcare-related field preferred.
• ACM, CCM, or CMAC certifications preferred; BLS required.

Responsibilities

• Collaborates with health care team to develop plan of care and patient flow.
• Reviews cases within 24–48 hours to plan discharge and transition needs.
• Navigates the care delivery system with physicians and other departments to ensure timely tests, treatments, and referrals.
• Communicates plan of care to patients, families, and care teams; intervenes to maintain progression.
• Documents the care plan and monitors metrics related to length of stay, readmissions, and resource use.

Education

RN licensure in the state of Massachusetts

Bachelor’s degree in nursing or healthcare-related field

ACM/CCM/CMAC certifications preferred; BLS required

Job description

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The RN Case Manager working in the Triad Model of Care Transitions partners with the interdisciplinary care team to facilitate the progression of care for the hospitalized patient. Together with the medical provider, the RN Case Manager collaborates with all members of the care team, focusing on the delivery of efficient, high-quality care. This position ensures the appropriate utilization of clinical resources with a goal of a safe and timely discharge for the patient. This role navigates health system services to support effective transitions while advising the team on healthcare industry compliance. The RN Case Manager must be adept at driving throughput metrics, clinical effectiveness, and fiscal responsibility.

Essential Functions:

The RN Case Manager collaborates with the health care team to develop the plan of care and patient flow.

Tasks:

• Reviews all cases within 24 – 48 hours or the next business day of admission/bed placement and each day throughout the stay to facilitate care progression to establish an anticipated length of stay and transition planning needs.
• Collaborates with the medical team to formulate a treatment plan to include care transitions and promote patient flow.
• Completes an initial assessment of all admissions/observation patients to identify barriers that impact the length of stay and discharge planning. The assessment should also identify the needs of the patients, acknowledge current resources available, and anticipate future resources needed to facilitate successful transitions.
• Navigates the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults, and procedures are appropriately indicated and performed timely.
• Articulates the plan of care and communicates this plan to other care team members and patient/caregiver. Intervenes to maintain care progression when a deviation in the plan occurs.

Influences positive outcomes by communicating the plan of care, expected discharge date, and transition needs to the patient/caregiver and team, thereby enhancing patient and staff satisfaction.

Tasks:

• Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver.
• Participates in daily multidisciplinary rounds incorporating evidence/best practice milestones in the plan and communicates that plan to the health care team.
• Apprises the interdisciplinary team of the estimated length of stay, care progression barriers, and anticipated disposition. Identifies what is needed from the team to facilitate the plan.
• Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to proper post-acute providers are initiated.
• Communicates the plan effectively with the patient and family/caregiver making certain that they have resources for success post-discharge.

Understands organizational goals for the length of stay and unplanned readmissions.

Tasks:

• Identifies appropriate clinical guidelines and directs the care plan to establish the anticipated length of stays and appropriate patient status.
• Proactively interfaces with the payer, where required, verifying coverage/benefits for anticipated discharge needs.
• Identifies patients that are at readmitted or at high risk for unplanned readmissions and initiates appropriate interventions. Identifies organizational resources within the community and engages those resources as necessary.
• Documents avoidable days (if not captured by another Care Transitions Team member), case management assessments, and care plans in a thorough and timely manner, per department policy.
• Ensures appropriate care provider documentation to support the patient’s anticipated discharge plan of care. Escalate deviations from the plan to the Physician Advisor as appropriate.

Possesses effective verbal and written communication, relationship‑building techniques, and negotiation skills.

Tasks:

• Completes clear and concise documentation of the care plan and communicates this to the interdisciplinary team and the patient‑caregiver.
• Identifies and communicates any problems or issues affecting patient flow, patient satisfaction, safety, length of stay management, or outcomes to the department director and/or appropriate key stakeholder.
• Functions as a resource for governmental and health care industry regulations and ensures compliance, communicates standards to the interdisciplinary team.
• Informs the patient and family/caregiver of the plan of care and the plan progression. Facilitates communication with the providers and encourages open dialogue.

Maintains current knowledge of organizational policies, care transitions, and clinical trends, as well as regulatory requirements for clinical care, discharge planning, and authorization for post‑acute services.

Tasks:

• Attends and contributes to departmental staff meetings.
• Participates and contributes to multi‑disciplinary committees and other committees or workgroups as directed.
• Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, and readmissions while suggesting strategies to improve organizational/departmental performance.

Contacts: Regular contacts, within or outside BILH, to give or get information.

Require courtesy, tact, and some knowledge of BILH procedures.

Qualifications/Requirements

Education Required:

RN licensure in the state of Massachusetts

Preferred:

Bachelor’s degree in nursing or another healthcare‑related field

Experience:

3- 5 years in an acute care setting

Certifications:

ACM, CCM, or CMAC preferred

BLS required

Physical Demands and Working Environment

Physical Demands:

Light - Exerts up to 20 lbs. of force occasionally and/or up to 10 lbs. frequently to move objects. Physical demands are more than those of sedentary work. Light work usually requires walking or standing to a significant degree.

Other -

Work Environment:

Normal Environment

• Normal light, air, and space in work environment.

Pay Range:

$39.14 - $101.14

The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled