Transitional Care Nurse

Beth Israel Lahey Health

Transitional Care Nurse coordinating patient care for medically complex patients after discharge. Working closely with healthcare teams to facilitate smooth transitions and adherence to care plans.

Posted 7/30/2026full-timeBeverly • Massachusetts • 🇺🇸 United StatesMid-LevelSenior💰 $32 - $55 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in patient-centered care coordination for high-risk patients, including telephonic assessments, medication reconciliation, and health coaching. Proficient in documenting encounters in EHR systems and collaborating with healthcare teams to ensure comprehensive care delivery.

Highest-signal resume keywords

Patient-Centered Care CoordinationTelephonic Patient AssessmentMedication ReconciliationEHR DocumentationHealth Coaching

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Patient AssessmentMedication ReconciliationCare CoordinationClinical Issue IdentificationHealth Education

Soft Skills

Detail OrientedTeam CollaborationSelf-Engagement Encouragement

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPointWeb-Based Applications

Certifications & Qualifications

Registered Nurse LicenseBasic Life Support Certificate

Industry Keywords

Patient Care ManagementDischarge PlanningHigh-Risk Patient CareCaregiver EducationHealthcare Collaboration

About the role

Key responsibilities & impact

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.
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.

Requirements

What you’ll need

Graduate from an accredited Nursing Program required.
Bachelor's degree in Nursing preferred.
License Registered Nurse preferred.
American Heart Association – Basic Life Support Certificate required.
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.
Advanced understanding of computer skills - email, typing, accessing work systems.

Benefits

Comp & perks

Health insurance
Paid time off
Professional development opportunities
Flexible work arrangements