Transitional Care Nurse Primary Care

Beth Israel Lahey Health • Needham, MA

5d • Hybrid

About The Position

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. This is a non-direct patient facing role.

Requirements

• Graduate from an accredited Nursing Program required.
• 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.
• American Heart Association – Basic Life Support Certificate required.

Nice To Haves

• Bachelor's degree in Nursing preferred.
• License Registered Nurse preferred.
• 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.

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.
• 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.

Benefits

• Pay Range: $30.00 – $44.58
• Pay Range: $32.24 - $55.32
• 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.
• Vaccinated against influenza (flu) as a condition of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree