Care Transitions RN Case Manager
Company: Beth Israel Deaconess Medical Center
Posted on: March 19, 2023
When you join the growing BILH team, you're not just taking a
job, you're making a difference in people's lives.Job
Type:RegularScheduled Hours:32Work Shift:Day (United States of
America)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.Job Description:Essential Functions:The RN
Case Manager collaborates with the health care team to develop the
plan of care and patient flow.Tasks:
- 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
- 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
- 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
- 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
- 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.Tasks:
- Identifies appropriate clinical guidelines and directs the care
plan to establish the anticipated length of stays and appropriate
- 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.Tasks:
- Completes clear and concise documentation of the care plan and
communicates this to the interdisciplinary team and the
- 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.Tasks:
- 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
performance.Contacts:------------Regular contacts, within or
outside BILH, to give or get information.Require courtesy, tact,
and some knowledge of BILH
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
preferred-- BLS requiredPhysical Demands and Working
EnvironmentPhysical Demands:Light - Exerts up to 20 lbs. of force
occasionally and/or up to 10 lbs. frequently to move objects.
Physical demands are more than those of sedentary work. Light work
usually requires walking or standing to a significant degree.Other
-Work Environment:Normal Environment- Normal light, air, and space
in work environment.FLSA Status:ExemptAs 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. 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
Keywords: Beth Israel Deaconess Medical Center, Boston , Care Transitions RN Case Manager, Executive , Boston, Massachusetts
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