Nurse Case Manager-Care Transitions

Company: Beth Israel Deaconess Medical Center
Location: Boston
Posted on: May 23, 2025

Job Description:

Job Type: RegularTime Type: Full timeWork Shift: Day (United States of America)FLSA Status: Non-ExemptWhen 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.The RN Case Manager 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 to establish an anticipated length of stay and transition planning needs.
• Collaborates with the medical team to formulate a treatment plan to include care transitions and promote patient flow.
• Completes an initial assessment of all admissions/observation patients to identify barriers that impact the length of stay and discharge planning. The assessment should also identify the needs of the patients, acknowledge current resources available, and anticipate future resources needed to facilitate successful transitions.
• Navigates the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults, and procedures are appropriately indicated and performed timely.
• Articulates the plan of care and communicates this plan to other care team members and patient/caregiver. Intervenes to maintain care progression when a deviation in the plan occurs. Influences positive outcomes by communicating the plan of care, expected discharge date, and transition needs to the patient/caregiver and team, thereby enhancing patient and staff satisfaction.
  • Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver.
  • Participates in daily multidisciplinary rounds incorporating evidence/best practice milestones in the plan and communicates that plan to the health care team.
  • Apprises the interdisciplinary team of the estimated length of stay, care progression barriers, and anticipated disposition. Identifies what is needed from the team to facilitate the plan.
  • Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to proper post-acute providers are initiated.
  • Communicates the plan effectively with the patient and family/caregiver making certain that they have resources for success post-discharge.
  • Understands organizational goals for the length of stay and unplanned readmissions.
  • Identifies appropriate clinical guidelines and directs the care plan to establish the anticipated length of stays and appropriate patient status.
  • Proactively interfaces with the payer, where required, verifying coverage/benefits for anticipated discharge needs.
  • Identifies patients that are at readmitted or at high risk for unplanned readmissions and initiates appropriate interventions. Identifies organizational resources within the community and engages those resources as necessary.
  • Documents avoidable days (if not captured by another Care Transitions Team member), case management assessments, and care plans in a thorough and timely manner, per department policy.
  • Ensures appropriate care provider documentation to support the patient's anticipated discharge plan of care. Escalate deviations from the plan to the Physician Advisor as appropriate. Possesses effective verbal and written communication, relationship-building techniques, and negotiation skills.
    • Completes clear and concise documentation of the care plan and communicates this to the interdisciplinary team and the patient-caregiver.
    • Identifies and communicates any problems or issues affecting patient flow, patient satisfaction, safety, length of stay management, or outcomes to the department director and/or appropriate key stakeholder.
    • Functions as a resource for governmental and health care industry regulations and ensures compliance, communicates standards to the interdisciplinary team.
    • Informs the patient and family/caregiver of the plan of care and the plan progression. Facilitates communication with the providers and encourages open dialogue. Maintains current knowledge of organizational policies, care transitions, and clinical trends, as well as regulatory requirements for clinical care, discharge planning, and authorization for post-acute services.
      • Attends and contributes to departmental staff meetings.
      • Participates and contributes to multi-disciplinary committees and other committees or workgroups as directed.
      • Manages quality indicators such as avoidable delays, length of stay, resource utilization, patient satisfaction, patient flow, outlier management, and readmissions while suggesting strategies to improve organizational/departmental performance. Education Required:RN licensure in the state of MassachusettsPreferred: Bachelor's degree in nursing or another healthcare-related fieldExperience: 3- 5 years in an acute care settingCertifications: ACM, CCM, or CMAC preferredBLS requiredAs 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) and COVID-19 as a condition of employment. Learn more about this requirement.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

Keywords: Beth Israel Deaconess Medical Center, Lynn , Nurse Case Manager-Care Transitions, Healthcare , Boston, Massachusetts