RN Care Transitions | Discharge & Care Coordination

Anna Jaques Hospital; Boston (MA); On-site; USD 54,000 - 139,000; Full time

Job summary

Beth Israel Lahey Health is seeking an RN Case Manager to partner with the interdisciplinary care team in the Triad Model of Care Transitions. The role focuses on efficient discharge planning, patient flow, and utilization of clinical resources to ensure safe transitions and high-quality care.

Responsibilities include leading transition plans, collaborating with physicians and social workers, and communicating the care plan to patients and families.

Qualifications

• RN licensure in Massachusetts is required or licensed in MA.
• Bachelor’s degree in nursing or related field preferred.
• ACM/CCM/CMAC certifications are preferred.
• BLS certification required.
• 3–5 years of experience in acute care setting preferred.

Responsibilities

• Reviews admission/discharge planning within 24–48 hours and throughout stay.
• Collaborates with medical team to formulate treatment plan and ensure timely care transitions.
• Document care plan, barriers to length of stay, and disposition.
• Coordinate transition plan with social workers, care providers, and post-acute services.
• Communicate plan of care to patient, family, and care team; escalate deviations when needed.
• Participate in multidisciplinary rounds and monitor quality indicators.

Skills

Care coordination

Discharge planning

Interdisciplinary collaboration

Throughput management

Education

RN licensure in Massachusetts

Bachelor’s degree in nursing or related field

ACM

CCM

CMAC

BLS

Job description

Beth Israel Lahey Health is seeking an RN Case Manager to partner with the interdisciplinary care team in the Triad Model of Care Transitions. The role focuses on efficient discharge planning, patient flow, and utilization of clinical resources to ensure safe transitions and high-quality care.

Responsibilities include leading transition plans, collaborating with physicians and social workers, and communicating the care plan to patients and families.