Care Transitions RN: Fast-Track Discharge & Care Coordination

Beth Israel Lahey Health; Massachusetts, United States, Northern America, Americas; Hybrid; USD 54,000 - 139,000; Part time

Job summary

Beth Israel Deaconess Medical Center is seeking an RN Case Manager to support Care Transitions in the Triad Model of Care. The role focuses on discharge planning, patient flow, and collaboration with an interdisciplinary team to ensure safe, timely transitions.

The candidate will review admissions promptly, assess care needs, and coordinate post-acute referrals while maintaining regulatory compliance and high-quality patient care.

Qualifications

• RN licensure in the state of Massachusetts
• Bachelor’s degree in nursing or related healthcare field preferred
• 3–5 years in an acute care setting preferred
• ACM/CCM/CMAC certifications preferred
• BLS required

Responsibilities

• Reviews admissions and bed placement within 24–48 hours to support transition planning.
• Collaborates with medical team to formulate treatment plans including care transitions and patient flow.
• Assesses admissions/observation patients to identify barriers to length of stay and discharge planning.
• Navigates care delivery systems with timely tests, treatments, and consults.
• Communicates plan of care and expected discharge date to patient, caregivers, and team.
• Coordinates the transition plan with social workers, care providers, and external services.
• Participates in daily rounds and informs team of length of stay and barriers.
• Ensures follow-up care and referrals to post-acute providers are arranged.

Skills

Verbal communication

Written communication

Relationship-building

Negotiation

Education

RN licensure in MA

Bachelor’s degree preferred

ACM or CCM certifications preferred

BLS certification required

Tools

N/A

Job description

Beth Israel Deaconess Medical Center is seeking an RN Case Manager to support Care Transitions in the Triad Model of Care. The role focuses on discharge planning, patient flow, and collaboration with an interdisciplinary team to ensure safe, timely transitions.

The candidate will review admissions promptly, assess care needs, and coordinate post-acute referrals while maintaining regulatory compliance and high-quality patient care.