Remote Transitional Care Nurse - Post-Discharge Coach

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

Job summary

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

The TCN will work with BIDHC providers to ensure comprehensive discharge planning, education for patients/caregivers, and documentation in the EHR.

Qualifications

• Graduate from an accredited Nursing Program required.
• Bachelor's degree in Nursing preferred.
• License Registered Nurse preferred, and American Heart Association – Basic Life Support Certificate required, or Licensed Practical Nurse (LPN) 3-5 years related work experience required.

Responsibilities

• Provide patient-centered coordination of care management to medically complex, high-risk patients discharged from inpatient facilities.
• Perform telephonic patient assessment from discharge summary to establish health status and barriers.
• This is a non-direct patient facing role.
• Complete discharge medication reconciliation and document encounters in the EHR.
• Review discharge instructions and coordinate follow-up tests, appointments, and care.
• Provide health coaching and education to patients/caregivers on discharge plans.
• Encourage self-engagement and identify barriers to adherence.
• Document encounters in EHR per BIDHC protocols.
• Identify clinical issues and escalate to providers as needed.
• Collaborate with providers and staff to ensure all aspects of the plan are met.

Skills

Nursing coordination

Communication skills

Team collaboration

Detail oriented

Microsoft Office

Education

Bachelor's degree in Nursing

Registered Nurse license

Tools

Microsoft Office

Job description

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

The TCN will work with BIDHC providers to ensure comprehensive discharge planning, education for patients/caregivers, and documentation in the EHR.