Care Transitions RN Case Manager

Beth Israel Lahey Health • Boston, MA

117d

About The Position

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. The RN Case Manager working in the Triad Model of Care Transitions partners with the interdisciplinary care team to facilitate the progression of care for the hospitalized patient. Together with the medical provider, the RN Case Manager collaborates with all members of the care team, focusing on the delivery of efficient, high-quality care. This position ensures the appropriate utilization of clinical resources with a goal of a safe and timely discharge for the patient. This role navigates health system services to support effective transitions while advising the team on healthcare industry compliance. The RN Case Manager must be adept at driving throughput metrics, clinical effectiveness, and fiscal responsibility.

Requirements

• RN licensure in the state of Massachusetts.
• 3-5 years in an acute care setting.
• BLS required.
• ACM, CCM, or CMAC preferred.

Nice To Haves

• Bachelor's degree in nursing or another healthcare-related field.

Responsibilities

• Collaborates with the health care team to develop the plan of care and patient flow.
• Reviews all cases within 24 - 48 hours or the next business day of admission/bed placement and each day throughout the stay to facilitate care progression.
• Completes an initial assessment of all admissions/observation patients to identify barriers that impact the length of stay and discharge planning.
• Navigates the care delivery system while collaborating with the physician and other clinical departments.
• Articulates the plan of care and communicates this plan to other care team members and patient/caregiver.
• Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers and other departments.
• Participates in daily multidisciplinary rounds incorporating evidence/best practice milestones.
• Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged.
• Identifies appropriate clinical guidelines and directs the care plan to establish the anticipated length of stays.
• Documents avoidable days, case management assessments, and care plans in a thorough and timely manner.
• Completes clear and concise documentation of the care plan and communicates this to the interdisciplinary team.
• Functions as a resource for governmental and health care industry regulations and ensures compliance.
• Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, and readmissions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: Bachelor's degree