RN Care Transitions Navigator for Discharge & Patient Flow

Beth Israel Lahey Health; Boston (MA); On-site; USD 54,000 - 139,000; Full time

Job summary

Beth Israel Lahey Health is seeking an RN Case Manager in the Triad Model of Care Transitions to partner with the interdisciplinary care team and support safe, timely discharge for hospitalized patients. You will review admissions within 24–48 hours, coordinate with physicians and social workers, and ensure appropriate utilization of resources to facilitate transitions.

The role emphasizes communication, adherence to regulatory guidelines, and ongoing collaboration to improve patient flow,

Qualifications

• RN licensure in the state of Massachusetts.
• Bachelor's degree in nursing or healthcare-related field preferred.
• ACM, CCM, or CMAC certifications preferred; BLS required.

Responsibilities

• Collaborates with health care team to develop plan of care and patient flow.
• Reviews cases within 24–48 hours to plan discharge and transition needs.
• Navigates the care delivery system with physicians and other departments to ensure timely tests, treatments, and referrals.
• Communicates plan of care to patients, families, and care teams; intervenes to maintain progression.
• Documents the care plan and monitors metrics related to length of stay, readmissions, and resource use.

Education

RN licensure in the state of Massachusetts

Bachelor’s degree in nursing or healthcare-related field

ACM/CCM/CMAC certifications preferred; BLS required

Job description

Beth Israel Lahey Health is seeking an RN Case Manager in the Triad Model of Care Transitions to partner with the interdisciplinary care team and support safe, timely discharge for hospitalized patients. You will review admissions within 24–48 hours, coordinate with physicians and social workers, and ensure appropriate utilization of resources to facilitate transitions.

The role emphasizes communication, adherence to regulatory guidelines, and ongoing collaboration to improve patient flow,