Care Transitions RN Case Manager, Per Diem, Boston

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.

Responsibilities

Reviews all cases within 24-48 hours or the next business day of admission/bed placement and each day throughout the stay; Collaborates with the medical team to formulate a treatment plan including care transitions and patient flow; Completes initial assessments of admissions/observation patients to identify barriers to length of stay and discharge planning; Creates and coordinates the overall transition plan of care; Participates in daily multidisciplinary rounds; Facilitates smooth care transitions and arranges clinical follow-up and post-acute referrals; Communicates the plan of care with patients and families; Proactively interfaces with payers to verify coverage/benefits; Identifies patients at high risk for unplanned readmissions and initiates interventions; Documents case management assessments and care plans; Functions as a resource for governmental and healthcare regulations and ensures compliance; Manages quality indicators such as avoidable delays, length of stay, and readmissions

Requirements

RN licensure in the state of Massachusetts; BLS required; 3-5 years experience in an acute care setting

Nice to have

Bachelor's degree in nursing or another healthcare-related field; ACM, CCM, or CMAC certification; Knowledge of BILH procedures