RN Case Manager – Care Transitions & Discharge Lead

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

Job summary

Qualifications

• RN licensure in Massachusetts is required.
• Bachelor’s degree in nursing or another healthcare-related field preferred.
• 3-5 years of acute care experience preferred but not required.
• ACM, CCM, or CMAC certifications preferred; BLS is required.

Responsibilities

• Coordinate transitions of care for hospitalized patients within the Triad Model.
• Perform initial assessments and identify barriers to discharge within 24-48 hours of admission or bed placement.
• Collaborate with physicians, social workers, and other team members to develop and execute the plan of care.
• Communicate discharge plans and post-acute needs to patients and families to optimize transition outcomes.
• Monitor length of stay, readmission risks, and regulatory compliance; escalate issues as needed.

Skills

Communication

Interdisciplinary collaboration

Care coordination

Education

RN licensure (MA)

Bachelor’s degree in nursing or healthcare

Job description