Beth Israel Deaconess Medical Center
Care Transitions RN Case Manager
Beth Israel Deaconess Medical Center, Boston, Massachusetts, us, 02298
Overview
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 works in the Triad Model of Care Transitions and partners with the interdisciplinary care team to facilitate the progression of care for hospitalized patients. The RN Case Manager collaborates with the medical provider and other care team members to deliver efficient, high-quality care, ensure appropriate utilization of clinical resources, and support safe and timely discharge. This role navigates health system services to support effective transitions, advises the team on healthcare industry compliance, and drives throughput metrics, clinical effectiveness, and fiscal responsibility. Job Description:
The RN Case Manager collaborates with the health care team to develop the plan of care and patient flow and ensures the plan supports timely transition planning and discharge. Responsibilities
Reviews all cases within 24–48 hours or the next business day of admission/bed placement and daily thereafter to facilitate care progression, establish anticipated length of stay, and transition planning needs. Collaborates with the medical team to formulate a treatment plan that includes care transitions and promotes patient flow. Completes an initial assessment of all admissions/observation patients to identify barriers impacting length of stay and discharge planning, including patient needs, available resources, and future resource needs to facilitate successful transitions. Navigates the care delivery system in collaboration with the physician and other clinical departments to ensure tests, treatments, consults, and procedures are appropriately indicated and performed timely. Articulates and communicates the plan of care to other care team members and patient/caregiver; intervenes to maintain care progression if deviations occur. 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 ongoing collaboration with social workers, direct care providers, hospital departments, external service organizations, agencies, and community care/navigation services, along with patient and family/caregiver. Participates in daily multidisciplinary rounds and communicates the plan to the health care team. Informs the interdisciplinary team of estimated length of stay, care progression barriers, and anticipated disposition; identifies what is needed from the team to facilitate the plan. Facilitates smooth transitions by ensuring appropriate clinical follow-up is arranged and referrals to post-acute providers are initiated. Communicates the plan effectively with the patient and family/caregiver, ensuring access to resources for success post-discharge. Understands organizational goals for length of stay and unplanned readmissions. Identifies appropriate clinical guidelines and directs the care plan to establish anticipated length of stay and patient status. Interacts with the payer as required to verify coverage/benefits for anticipated discharge needs. Identifies patients at risk for readmission and initiates appropriate interventions; engages community resources as necessary. Documents avoidable days, case management assessments, and care plans in a timely manner per department policy. Ensures documentation supports the patient’s discharge plan and escalates deviations to the Physician Advisor as appropriate. Possesses effective verbal and written communication, relationship-building, and negotiation skills. Completes clear and concise documentation of the care plan and communicates it to the interdisciplinary team and patient-caregiver. Identifies and communicates issues affecting patient flow, satisfaction, safety, length of stay, or outcomes to the department director and key stakeholders. Functions as a resource for regulations and ensures team compliance; communicates standards to the interdisciplinary team. Informs the patient and family/caregiver of the plan of care and progression; facilitates open dialogue with providers. Maintains current knowledge of organizational policies, care transitions, clinical trends, and regulatory requirements for clinical care, discharge planning, and authorization for post-acute services. Attends departmental staff meetings and participates in multidisciplinary 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, suggesting strategies to improve performance. Contacts:
Regular contacts within or outside BILH to exchange information; requires courtesy, tact, and knowledge of BILH procedures. Qualifications/Requirements Education Required:
RN licensure in the state of Massachusetts Preferred:
Bachelor’s degree in nursing or another healthcare-related field Experience:
3–5 years in an acute care setting Certifications:
ACM, CCM, or CMAC preferred; BLS required Physical Demands and Working Environment Physical Demands:
Light – Exerts up to 20 lbs occasionally and/or up to 10 lbs frequently; more than sedentary work; walking/standing required. Work Environment:
Normal environment; normal light, air, and space in work environment. As a health care organization, we have a responsibility to care for and protect our patients, colleagues, and communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Equal Opportunity Employer/Veterans/Disabled 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.
#J-18808-Ljbffr
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 works in the Triad Model of Care Transitions and partners with the interdisciplinary care team to facilitate the progression of care for hospitalized patients. The RN Case Manager collaborates with the medical provider and other care team members to deliver efficient, high-quality care, ensure appropriate utilization of clinical resources, and support safe and timely discharge. This role navigates health system services to support effective transitions, advises the team on healthcare industry compliance, and drives throughput metrics, clinical effectiveness, and fiscal responsibility. Job Description:
The RN Case Manager collaborates with the health care team to develop the plan of care and patient flow and ensures the plan supports timely transition planning and discharge. Responsibilities
Reviews all cases within 24–48 hours or the next business day of admission/bed placement and daily thereafter to facilitate care progression, establish anticipated length of stay, and transition planning needs. Collaborates with the medical team to formulate a treatment plan that includes care transitions and promotes patient flow. Completes an initial assessment of all admissions/observation patients to identify barriers impacting length of stay and discharge planning, including patient needs, available resources, and future resource needs to facilitate successful transitions. Navigates the care delivery system in collaboration with the physician and other clinical departments to ensure tests, treatments, consults, and procedures are appropriately indicated and performed timely. Articulates and communicates the plan of care to other care team members and patient/caregiver; intervenes to maintain care progression if deviations occur. 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 ongoing collaboration with social workers, direct care providers, hospital departments, external service organizations, agencies, and community care/navigation services, along with patient and family/caregiver. Participates in daily multidisciplinary rounds and communicates the plan to the health care team. Informs the interdisciplinary team of estimated length of stay, care progression barriers, and anticipated disposition; identifies what is needed from the team to facilitate the plan. Facilitates smooth transitions by ensuring appropriate clinical follow-up is arranged and referrals to post-acute providers are initiated. Communicates the plan effectively with the patient and family/caregiver, ensuring access to resources for success post-discharge. Understands organizational goals for length of stay and unplanned readmissions. Identifies appropriate clinical guidelines and directs the care plan to establish anticipated length of stay and patient status. Interacts with the payer as required to verify coverage/benefits for anticipated discharge needs. Identifies patients at risk for readmission and initiates appropriate interventions; engages community resources as necessary. Documents avoidable days, case management assessments, and care plans in a timely manner per department policy. Ensures documentation supports the patient’s discharge plan and escalates deviations to the Physician Advisor as appropriate. Possesses effective verbal and written communication, relationship-building, and negotiation skills. Completes clear and concise documentation of the care plan and communicates it to the interdisciplinary team and patient-caregiver. Identifies and communicates issues affecting patient flow, satisfaction, safety, length of stay, or outcomes to the department director and key stakeholders. Functions as a resource for regulations and ensures team compliance; communicates standards to the interdisciplinary team. Informs the patient and family/caregiver of the plan of care and progression; facilitates open dialogue with providers. Maintains current knowledge of organizational policies, care transitions, clinical trends, and regulatory requirements for clinical care, discharge planning, and authorization for post-acute services. Attends departmental staff meetings and participates in multidisciplinary 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, suggesting strategies to improve performance. Contacts:
Regular contacts within or outside BILH to exchange information; requires courtesy, tact, and knowledge of BILH procedures. Qualifications/Requirements Education Required:
RN licensure in the state of Massachusetts Preferred:
Bachelor’s degree in nursing or another healthcare-related field Experience:
3–5 years in an acute care setting Certifications:
ACM, CCM, or CMAC preferred; BLS required Physical Demands and Working Environment Physical Demands:
Light – Exerts up to 20 lbs occasionally and/or up to 10 lbs frequently; more than sedentary work; walking/standing required. Work Environment:
Normal environment; normal light, air, and space in work environment. As a health care organization, we have a responsibility to care for and protect our patients, colleagues, and communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. Equal Opportunity Employer/Veterans/Disabled 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.
#J-18808-Ljbffr