When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
JOB SUMMARY:
Beth Israel Lahey Health and Mount Auburn Hospital are devoted to consistently promoting a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in our organization's WE CARE values which can be reviewed here Mission, Vision & Values | Mount Auburn Hospital.
The Case Manager Registered Nurse (RN) is responsible for coordinating and facilitating patient-centered care across the continuum, ensuring timely, effective, and appropriate utilization of healthcare resources. Working collaboratively with physicians, advanced practice providers, nursing staff, social workers, rehabilitation services, and community agencies, the Case Manager RN assesses patient needs, develops discharge and transition plans, and promotes optimal clinical outcomes.
The Case Manager RN serves as a patient advocate and resource, supporting care progression, discharge planning, utilization management, readmission prevention, and continuity of care in accordance with Mount Auburn Hospital, Beth Israel Lahey Health, state, federal, and regulatory standards. This role reports to the nurse manager of care transitions.
Job Description:
ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to):
Care Coordination
· Conduct comprehensive assessments of patients' clinical, psychosocial, functional, and discharge planning needs.
· Develop and implement individualized plans of care in collaboration with patients, families, physicians, and interdisciplinary team members.
· Facilitate smooth transitions across levels of care, including home, rehabilitation, skilled nursing facilities, long-term acute care, hospice, and community-based services.
· Participate in interdisciplinary rounds and care conferences.
· Coordinate services among hospital departments and external providers to eliminate barriers to care.
Discharge Planning
· Lead the discharge planning process from admission through discharge.
· Identify patients at risk for complex discharges, prolonged hospitalization, or readmission.
· Arrange post-acute services, durable medical equipment, home care, transportation, and community resources as needed.
· Educate patients and families regarding discharge instructions and available support services.
· Ensure discharge plans meet regulatory and payer requirements.
Patient Advocacy
· Act as an advocate for patients and families while balancing clinical, regulatory, and financial considerations.
· Promote patient autonomy and participation in healthcare decision-making.
· Facilitate discussions regarding goals of care and care options when appropriate.
Quality Improvement & Compliance
· Participate in quality improvement initiatives related to care transitions, readmissions, patient outcomes, and patient satisfaction.
· Maintain compliance with all applicable hospital, accreditation, state, and federal regulations.
· Collect and document required data related to case management activities and outcome measures.
· Support departmental performance improvement efforts and best practice initiatives.
Documentation
· Maintain timely, accurate, and complete documentation within the electronic medical record.
· Document assessments, care coordination activities, utilization reviews, discharge plans, and patient outcomes according to departmental standards.
Other Duties
· Serve as a resource to clinical staff regarding care transitions, discharge planning, and community resources.
· Participate in departmental meetings, educational programs, and professional development activities.
· Perform other duties as assigned.
QUALIFICATIONS:
Education
· Bachelor of Science in Nursing (BSN) required or obtained within organizational…