Care Transitions RN Case Manager, Per Diem, Boston
About The Position
The RN Case Manager works in the Triad Model of Care Transitions and partners with the interdisciplinary care team to facilitate progression of care for hospitalized patients. In collaboration with medical providers and other team members, this position supports efficient, high-quality care, appropriate use of clinical resources, and safe, timely discharge. The role navigates health system services, advises the team on healthcare industry compliance, and supports throughput, clinical effectiveness, and fiscal responsibility. The RN Case Manager assesses patients and coordinates care plans and transitions throughout the hospitalization. The position communicates anticipated length of stay, care progression barriers, discharge plans, and post-acute needs to patients, caregivers, and the interdisciplinary team. It also monitors utilization, length of stay, avoidable delays, readmissions, patient satisfaction, and other quality indicators while helping ensure regulatory compliance and effective use of organizational and community resources.
Requirements
- Current RN licensure in Massachusetts.
- Three to five years of experience in an acute care setting.
- BLS certification required.
- Effective verbal and written communication, relationship-building, and negotiation skills.
Nice To Haves
- Bachelor’s degree in nursing or another healthcare-related field preferred.
- ACM, CCM, or CMAC certification preferred.
Responsibilities
- Review cases within 24–48 hours or the next business day after admission or bed placement, and daily throughout the stay, to support care progression, establish anticipated length of stay, and identify transition-planning needs.
- Collaborate with the medical team to develop treatment plans that include care transitions and promote patient flow.
- Assess admissions and observation patients to identify needs, barriers affecting length of stay or discharge, available resources, and anticipated future resources.
- Coordinate with physicians and clinical departments to ensure tests, treatments, consultations, and procedures are appropriately indicated and completed in a timely manner.
- Communicate the plan of care to the care team and patient or caregiver, and intervene when the plan deviates.
- Create and coordinate transition plans with social workers, providers, hospital departments, external organizations, agencies, healthcare facilities, community services, patients, and caregivers.
- Participate in daily multidisciplinary rounds, incorporate evidence-based or best-practice milestones into plans, and communicate plans to the care team.
- Inform the interdisciplinary team of estimated length of stay, barriers to progression, anticipated disposition, and support needed to advance the plan.
- Arrange appropriate clinical follow-up and initiate referrals to post-acute providers.
- Ensure patients and caregivers understand the care plan and have resources for success after discharge.
- Apply clinical guidelines to guide care plans, anticipated length of stay, and appropriate patient status.
- Interface with payers as required to verify coverage and benefits for anticipated discharge needs.
- Identify patients at risk of readmission and initiate interventions, engaging appropriate community resources.
- Document avoidable days, assessments, and care plans thoroughly and promptly according to department policy.
- Ensure provider documentation supports the anticipated discharge plan and escalate deviations to the Physician Advisor when appropriate.
- Identify and communicate issues affecting patient flow, satisfaction, safety, length-of-stay management, or outcomes to department leadership or other stakeholders.
- Serve as a resource on governmental and healthcare industry regulations and communicate standards to the interdisciplinary team.
- Maintain current knowledge of organizational policies, care transitions, clinical trends, and regulatory requirements for clinical care, discharge planning, and post-acute authorization.
- Attend and contribute to departmental meetings and participate in multidisciplinary committees, workgroups, or other committees as directed.
- Manage quality indicators, including avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, and readmissions, and suggest performance-improvement strategies.
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
