RN Care Transitions: Lead Seamless Discharges

Beth Israel Lahey Health; United States; On-site; USD 54,000 - 139,000; Full time

Job summary

Beth Israel Lahey Health is seeking an RN Case Manager for the Triad Model of Care Transitions to partner with the interdisciplinary care team and drive safe, timely discharges. You will assess admissions, coordinate transitions, and ensure appropriate utilization of clinical resources while maintaining high-quality patient care.

You will lead daily rounds, communicate plans to the team and patient, and work with payers and post-acute providers to optimize length of stay, readmissions, and

Qualifications

• RN licensure in the state of Massachusetts.
• Bachelor's degree in nursing or another healthcare-related field is preferred.
• 3–5 years in an acute care setting.
• ACM, CCM, or CMAC certifications are preferred.
• BLS certification is required.

Responsibilities

• Reviews all cases within 24–48 hours or the next business day of admission/bed placement and daily thereafter to plan care progression and LOS.
• Collaborates with the medical team to formulate a treatment plan including care transitions and patient flow.
• Completes an initial assessment of admissions/observation patients to identify barriers to LOS and discharge planning.
• Navigates the care delivery system with physicians and departments to ensure timely tests, treatments, consults, and procedures.
• Articulates the plan of care to the team and patient/caregiver and intervenes to maintain progression when deviations occur.
• Creates and coordinates the overall transition plan of care with social workers, direct care providers, other departments, external services, and family/caregiver.
• Participates in daily multidisciplinary rounds and communicates the plan to the health care team.
• Informs the team of LOS estimates, barriers, and disposition needs; specifies what's required to facilitate the plan.
• Facilitates smooth transitions by arranging follow-up and referrals to post-acute providers.
• Communicates the plan to the patient/family, ensuring resources for success post-discharge.

Education

RN licensure in the state of Massachusetts

Bachelor’s degree in nursing or another healthcare-related field

Job description

Beth Israel Lahey Health is seeking an RN Case Manager for the Triad Model of Care Transitions to partner with the interdisciplinary care team and drive safe, timely discharges. You will assess admissions, coordinate transitions, and ensure appropriate utilization of clinical resources while maintaining high-quality patient care.

You will lead daily rounds, communicate plans to the team and patient, and work with payers and post-acute providers to optimize length of stay, readmissions, and