Remote Transitional Care Nurse Discharge and Coordination

Beth-Israel-Lahey-Health; Needham (MA); Hybrid; USD 44,000 - 76,000; Full time

Job summary

Beth Israel Lahey Health Primary Care is seeking a Transitional Care Nurse (TCN) to support post-discharge coordination for medically complex patients. This hybrid role starts with onsite training in the North Shore area and emphasizes patient-centered care, safe transitions, and effective communication with BIDHC providers.

The ideal candidate has nursing credentials, experience in care coordination and discharge planning, and can deliver education to patients and families while documenting

Qualifications

• Graduate from an accredited Nursing Program is required.
• Bachelor's degree in Nursing preferred.
• RN licensure or LPN option considered with relevant experience.

Responsibilities

• Provide patient-centered care coordination for medically complex patients post-discharge.
• Perform telephonic assessments to identify health status and barriers.
• Complete discharge medication reconciliation and document in EHR.
• Provide health coaching and education to patients and caregivers.

Skills

Care coordination

Telephonic assessment

Discharge planning

Microsoft Office

Written communications

Teamwork

Problem solving

Education

Bachelor's degree in Nursing

RN licensure

Tools

EHR systems

Job description

Beth Israel Lahey Health Primary Care is seeking a Transitional Care Nurse (TCN) to support post-discharge coordination for medically complex patients. This hybrid role starts with onsite training in the North Shore area and emphasizes patient-centered care, safe transitions, and effective communication with BIDHC providers.

The ideal candidate has nursing credentials, experience in care coordination and discharge planning, and can deliver education to patients and families while documenting