Job Description

**Job Type:** Regular **Time Type:** Full time **Work Shift:** Day (United States of America) **FLSA Status:** Non-Exempt **When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.** The Transitional Care Nurse (TCN) ensures that identified Beth Israel Lahey Health Primary Care Health (BILHPC) 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 BILHPC 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 BILHPC locations. **Job Description:** **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 BILHPC 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 American Heart Association - Basic Life Support Certificate 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. **Competencies:** **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 Hybrid role/ 40 hours **As 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. Learn more ( 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** **Employer/Veterans/Disabled**

Job Tags

Full time, Work experience placement, Shift work,

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