Transitional Care Nurse Primary Care

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

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. We are looking for an experienced nurse to support our coordination of care management for primary care patients.

This role is primarily remote with initial onsite training in the North Shore area. The Transitional Care Nurse (TCN) ensures that identified Beth Israel Deaconess HealthCare (BIDHC) patients discharged from an inpatient setting transition safely to the patient's home/community setting. This position will utilize appropriate resources, follow best practice guidelines and provide post discharge outreach for medically complex patients.

The TCN will work collaboratively with BIDHC providers and practice staff to ensure safe and seamless transitions of care for the patient. The TCN will utilize clinical nursing skills using the highest standards of patient care, critical thinking and patient advocacy for coordination of care. The TCN will provide clinical and educational consultation to patients/caregivers to ensure the discharge plan of care is implemented. The TCN is a supportive role to BIDHC practice locations.

Essential Responsibilities

• Provide patient-centered coordination of care management to medically complex, high-risk patients who have been discharged from an acute or sub-acute inpatient facility.
• Perform telephonic patient assessment with information obtained from discharge summary and patient/caregiver to establish patient health status, identify early health issues and potential barriers of the discharge plan of care.
• This is a non direct patient facing role.
• Complete discharge medication reconciliation, identify discrepancies or adherence barriers and accurately document the encounter in the medical record.
• Review discharge summary instructions and provide care coordination, follow up lab and diagnostic studies, specialty and primary care provider appointments.
• Provide health coaching and education to patient/caregiver on discharge summary plan of care.
• Encourage self-engagement with a focus on achievement of goals and identifies barriers to adherence.
• Document summary of the patient/caregiver encounter in patient's EHR according to BIDHC protocols.
• Identifies clinical issues and lapses in standards of care and notifies appropriate provider and staff.
• Collaborates with provider or other practice team members to ensure all aspects of patient’s plan of care has been met.

Required 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.
• Detail oriented with the ability to work in a fast paced, high call volume team environment.
• Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications.
• May produce complex documents, perform analysis and maintain databases.
• Advanced understanding of computer skills - email, typing, accessing work systems.

Preferred Qualifications

• Previous nursing case management or medical/surgical experience.
• VNA Skills.
• Nursing telephone triage, Chronic Care Management (CCM), discharge planning, skilled telephonic patient interaction and primary care/ambulatory care experience.

Competencies

Decision Making

Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

Problem Solving

Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.

Independence of Action

Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.

Written Communications

Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

Oral Communications

Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

Knowledge

Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.

Team Work

Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.

Customer Service

Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Hybrid role

Pay Range: $32.24 - $55.32

The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled At Beth Israel Lahey Health, we are driving the change in health care that Massachusetts wants and needs. Our culture promotes continuous learning, growth, innovation and a sense of belonging. We make it a priority to offer comprehensive compensation and benefits and help you achieve a healthy and balanced life.

While you're busy caring for and supporting our patients, we take care of you.