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 requirements.
· Master's degree in Nursing, Healthcare Administration, Public Health, or related field preferred.
Licensure & Certification
· Current Registered Nurse (RN) license in the Commonwealth of Massachusetts.
· Basic Life Support (BLS) certification required.
· Certification in Case Management preferred:
o CCM (Certified Case Manager)
o ACM-RN (Accredited Case Manager)
o CMAC (Case Management Administrator Certification)
Experience
· Minimum of three (3) years of acute care nursing experience required.
· Previous case management, care coordination, utilization review, discharge planning, population health, or transition of care experience preferred.
· Experience with Epic electronic health record preferred.
OTHER REQUIREMENTS:
Clinical Knowledge
· Strong understanding of acute care nursing practice, care transitions, utilization management, and discharge planning principles.
· Knowledge of Medicare, Medicaid, commercial insurance requirements, and post-acute care resources.
Communication
· Excellent verbal and written communication skills.
· Ability to communicate effectively with patients, families, physicians, and interdisciplinary team members.
Critical Thinking
· Ability to assess complex situations and develop practical solutions.
· Strong analytical and problem-solving skills.
Organizational Skills
· Ability to prioritize multiple responsibilities in a fast-paced healthcare environment.
· Strong attention to detail and documentation accuracy.
Teamwork
· Demonstrated ability to work collaboratively across disciplines.
· Commitment to fostering a respectful and patient-centered environment.
· Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values.
· Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment.
Mount Auburn Hospital Values
The Case Manager RN demonstrates a commitment to:
· Patient-centered care
· Quality and safety
· Collaboration and teamwork
· Respect and compassion
· Diversity, equity, and inclusion
· Continuous improvement and professional excellence
This position plays a critical role in ensuring safe, efficient, and patient-focused transitions of care throughout the Mount Auburn Hospital continuum.
Pay Range:
$38.11 – $98.23
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. 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.
