Remote Transitional Care Nurse — Care Coordination Expert

Beth Israel Lahey Health, Inc.; Northern (KY); Hybrid; USD 44,000 - 76,000; Full time

Job summary

Beth Israel Lahey Health Primary Care is seeking an experienced Transitional Care Nurse to support care coordination for primary care patients. The role is primarily remote with initial onsite training in the North Shore area, focusing on safe transitions from inpatient settings to home.

Responsibilities include telephonic assessments, discharge planning, medication reconciliation, health coaching, and documentation in the EHR.

Qualifications

• Graduate from an accredited nursing program is required.
• RN license required; BLS expected.
• 3–5 years related nursing experience is preferred.
• Advanced computer skills and proficiency with common software applications are required.

Responsibilities

• Provide telephonic patient assessments using discharge information to assess health status and barriers to the plan.
• Perform discharge medication reconciliation and document accurately in the EHR.
• Review discharge instructions and coordinate follow-up lab and specialty/primary care appointments.
• Provide health coaching and education to patient/caregiver regarding the discharge plan of care.
• Document encounters in the EHR and collaborate with the care team to ensure all plan elements are met.

Skills

Care coordination

Telephonic assessment

Discharge planning

Patient education

Team coordination

Education

Bachelor's degree in Nursing

Registered Nurse license

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Beth Israel Lahey Health Primary Care is seeking an experienced Transitional Care Nurse to support care coordination for primary care patients. The role is primarily remote with initial onsite training in the North Shore area, focusing on safe transitions from inpatient settings to home.

Responsibilities include telephonic assessments, discharge planning, medication reconciliation, health coaching, and documentation in the EHR.