Case Manager, Mount Auburn in Cambridge , MA

Beth Israel Lahey Health•Cambridge, MA

13d•$38 - $98•Onsite

About The Position

The Case Manager Registered Nurse (RN) coordinates and facilitates patient-centered care across the continuum, ensuring timely, effective, and appropriate use of healthcare resources. Working with physicians, advanced practice providers, nursing staff, social workers, rehabilitation services, and community agencies, the RN assesses patient needs, develops discharge and transition plans, and promotes optimal clinical outcomes. The Case Manager RN acts as a patient advocate and resource, supporting care progression, discharge planning, utilization management, readmission prevention, and continuity of care in accordance with Mount Auburn Hospital, Beth Israel Lahey Health, and applicable state, federal, and regulatory standards. The position reports to the nurse manager of care transitions. This role is critical to safe, efficient, patient-focused transitions throughout the Mount Auburn Hospital continuum. The Case Manager RN is expected to promote the organization’s WE CARE values: Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity, and to contribute to an inclusive working and learning environment.

Requirements

Bachelor of Science in Nursing (BSN), required or to be obtained within organizational requirements.
Current Registered Nurse (RN) license in the Commonwealth of Massachusetts.
Basic Life Support (BLS) certification.
At least three years of acute care nursing experience.
Strong understanding of acute care nursing practice, care transitions, utilization management, and discharge planning principles.
Knowledge of Medicare, Medicaid, commercial insurance requirements, and post-acute care resources.
Excellent verbal and written communication skills, including the ability to communicate effectively with patients, families, physicians, and interdisciplinary team members.
Ability to assess complex situations and develop practical solutions; strong analytical and problem-solving skills.
Ability to prioritize multiple responsibilities in a fast-paced healthcare environment, with strong attention to detail and documentation accuracy.
Demonstrated ability to work collaboratively across disciplines and commitment to a respectful, patient-centered environment.
Commitment to valuing diversity and contributing to an inclusive working and learning environment.
Commitment to patient-centered care, quality and safety, collaboration and teamwork, respect and compassion, diversity, equity and inclusion, continuous improvement, and professional excellence.
Staff must be vaccinated against influenza as a condition of employment.

Nice To Haves

Master’s degree in Nursing, Healthcare Administration, Public Health, or a related field.
Certification in case management, such as CCM (Certified Case Manager), ACM-RN (Accredited Case Manager), or CMAC (Case Management Administrator Certification).
Previous experience in case management, care coordination, utilization review, discharge planning, population health, or transitions of care.
Experience with the Epic electronic health record.

Responsibilities

Conduct comprehensive assessments of patients’ clinical, psychosocial, functional, and discharge-planning needs.
Develop and implement individualized plans of care with patients, families, physicians, and interdisciplinary team members.
Facilitate transitions across levels of care, including home, rehabilitation, skilled nursing facilities, long-term acute care, hospice, and community-based services.
Participate in interdisciplinary rounds and care conferences.
Coordinate services among hospital departments and external providers to eliminate barriers to care.
Lead discharge planning from admission through discharge.
Identify patients at risk for complex discharges, prolonged hospitalization, or readmission.
Arrange post-acute services, durable medical equipment, home care, transportation, and community resources as needed.
Educate patients and families about discharge instructions and available support services.
Ensure discharge plans meet regulatory and payer requirements.
Advocate for patients and families while balancing clinical, regulatory, and financial considerations.
Promote patient autonomy and participation in healthcare decision-making.
Facilitate discussions regarding goals of care and care options when appropriate.
Participate in quality improvement initiatives related to care transitions, readmissions, patient outcomes, and patient satisfaction.
Maintain compliance with applicable hospital, accreditation, state, and federal regulations.
Collect and document required data related to case management activities and outcome measures.
Support departmental performance improvement efforts and best-practice initiatives.
Maintain timely, accurate, and complete documentation in the electronic medical record, including assessments, care coordination activities, utilization reviews, discharge plans, and patient outcomes.
Serve as a resource to clinical staff regarding care transitions, discharge planning, and community resources.
Participate in departmental meetings, educational programs, and professional development activities.
Perform other duties as assigned.