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Beth Israel Deaconess Medical Center Transitional Care Nurse (Case Management)-LPNs welcome! in Needham, Massachusetts

Transitional Care Nurse (Case Management)-LPNs welcome!

Needham, Massachusetts

Department: Beth Israel Deaconess HealthCare-Central Nursing

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At Beth Israel Deaconess Medical Center our nurses make a difference each and every day. Here you will work in a collaborative environment where our patients come first. You are a patient advocate delivering compassionate care while ensuring safe nursing practices. We are Harvard with a heart and strive to build on our legacy of nursing excellence.

  • Full Time

  • Level: 1 + Years

  • RN License

  • Indeed

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  • 2,955

nurses at BIDMC, ensuring

every patient receives

personalized care

  • 92%

of our nurses have a

bachelor's, master's,

or doctorate degree

  • 130,000

dollars in scholarships awarded annually for

academic advancement

in nursing


  • Collaboration

  • 401k/Retirement Savings

  • Continuing Education

  • Amenities

  • Health and Wellness Programs

  • $5 Red Sox Tickets

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Department Description:Beth Israel Deaconess HealthCare is a network of more than 100 highly-skilled primary care physicians and specialists who are affiliated with the renowned Beth Israel Deaconess Medical Center in Boston, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Milton and Beth Israel Deaconess Hospital-Plymouth. Our Central Office is located in Needham, MA.

Job Location:Needham, MA

Req ID:39302BR

Job Summary:The Transitional Care Nurse (TCN) ensures that identified Beth Israel Deaconess HealthCare (BIDHC) patients discharged from an inpatient setting transition safely to the patient's home/community setting.This position will utilize appropriate resources, follow best practice guidelines and provide post discharge outreach for medically complex patients. The TCN will work collaboratively with BIDHC providers and practice staff to ensure safe and seamless transitions of care for the patient. The TCN will utilize clinical nursing skills using the highest standards of patient care, critical thinking and patient advocacy for coordination of care. The TCN will provide clinical and educational consultation to patients/caregivers to ensure the discharge plan of care is implemented. The TCN is a supportive role to BIDHC practice locations.

Essential Responsibilities:

  • Provide patient-centered coordination of care management to medically complex, high-risk patients who have been discharged from an acute or sub-acute inpatient facility.

  • Perform telephonic patient assessment with information obtained from discharge summary and patient/caregiver to establish patient health status, identify early health issues and potential barriers of the discharge plan of care. This is a non direct patient facing role.

  • Complete discharge medication reconciliation, identify discrepancies or adherence barriers and accurately document the encounter in the medical record. Review discharge summary instructions and provide care coordination, follow up lab and diagnostic studies, specialty and primary care provider appointments.

  • Provide health coaching and education to patient/caregiver on discharge summary plan of care. Encourage self-engagement with a focus on achievement of goals and identifies barriers to adherence.

  • Document summary of the patient/caregiver encounter in patient's EHR according to BIDHC protocols. Identifies clinical issues and lapses in standards of care and notifies appropriate provider and staff. Collaborates with provider or other practice team members to ensure all aspects of patient's plan of care has been met.

Required Qualifications:

  • Graduate from an accredited Nursing Program required. Bachelor's degree in Nursing preferred.

  • License Registered Nurse preferred., and Certificate 1 Basic Life Support required., or Licensed Practical Nurse (LPN)

  • 3-5 years related work experience required.

  • Detail oriented with the ability to work in a fast paced, high call volume team environment.

  • Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.

Preferred Qualifications:

  • Previous nursing case management or medical/surgical experience

  • Nursing telephone triage, Chronic Care Management (CCM), discharge planning, skilled telephonic patient interaction and primary care/ambulatory care experience.


  • Decision Making:Ability to make decisions that are guided by precedents, policies and objectives. Regularly makes decisions and recommendations on issues affecting a department or functional area.

  • Problem Solving:Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.

  • Independence of Action:Ability to set goals and determines how to accomplish defined results with some guidelines. Manager/Director provides broad guidance and overall direction.

  • Written Communications:Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.

  • Oral Communications:Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.

  • Knowledge:Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.

  • Team Work:Ability to act as a team leader for small projects or work groups, creating a collaborative and respectful team environment and improving workflows. Results may impact the operations of one or more departments.

  • Customer Service:Ability to provide a high level of customer service and staff training to meet customer service standards and expectations for the assigned unit(s). Resolves service issues in the assigned unit(s) in a timely and respectful manner.

Age based Competencies:

Employees in this job must be competent to provide patient care to the following age groups: Neonatal:Birth to 6 months, Youth: 6 months to 16 years, Young adult: 16-30 years, Middle Age: 30 - 60 years, Elderly: 60 -.

Physical Nature of the Job:

Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally